At first, the UK approach to testing appeared to be going well. On February 16, when there were still only nine confirmed Covid-19 cases in the UK, authorities had carried out more than 3,000 tests. Twelve days later, the NHS launched drive-through sites where samples could be collected from local people, as long as they had been referred for testing through NHS 111.
Then things started to unravel. Up until March 12, the criteria for testing in official documents included cases in the community. But, the next day, the advice changed dramatically. Testing was to be offered to hospitalised cases, meaning that it was available to inpatients only.
Why the UK started out with one approach and then pivoted to another, has never been fully explained. Now, just over a month later, the country seems to have reverted – to some extent – to the original approach. The government says it is keen to test healthcare workers and care home staff, and that it is pursuing a new goal of reaching 100,000 tests per day. But, as of April 16, just 21,328 people had been tested in a single day. How did the UK manage to fall behind on testing so woefully?
Among those who are pleased to see widespread screening for Covid-19 become a priority again is Devi Sridhar, professor of global public health at the University of Edinburgh. Sridhar has repeatedly stressed the importance of testing as a means to an end. That is, through better understanding the prevalence of Covid-19 in the UK, the government will be better equipped to decide how and where to tackle it. But she worries that those in charge have wasted time.
“We’re so late,” she says. “We’re now shifting on to where other countries were weeks ago – ‘testing is important, how do we do it?’” Data from various countries on the number of tests per 1,000 citizens show the extent of the UK’s delayed response: countries including Estonia, Ireland, Australia, Portugal, Latvia, Slovenia, New Zealand, Russia, and the United States, are all are ahead of the UK, as of April 17.
At the beginning of the coronavirus outbreak, the UK government seemed committed to testing, but this initial enthusiasm quickly waned. Whether or not pursuit of “herd immunity”, by allowing the disease to spread, was behind it, policies determining who could get a test clearly changed – and they are now being revised yet again.
As Sridhar suggests, it has left the UK lamentably late in implementing diagnostics. One virologist wrote on Twitter, “We were under-prepared because we didn’t prepare the infrastructure for testing and treatment when we could see the way Italy was going […].” A consultant clinical scientist has also decried what he calls the “bureaucratic shambles” that means some labs with capacity to carry out more tests are being under-utilised.
A source at an NHS microbiology lab in the south of England, who wishes to remain anonymous, told WIRED: “They have been moving the goalposts on us constantly. We’ve increased our capacity, but the number of samples coming in has dropped. If there are labs who are struggling to keep up, why aren’t labs like mine being asked to help?”
There are two main Covid-19 tests – PCR tests that detect viral RNA in samples taken from a patient’s nose or throat, and tests that look for antibodies in a small blood sample. People naturally produce antibodies as they fight off a viral infection, so in patients without symptoms the presence of antibodies would suggest that that person recently had the disease but has recovered. However, the UK has still not validated antibody tests for mass use: when we talk about UK testing, we’re almost exclusively talking about PCR tests that detect the virus in people who are currently infected.
Such tests have to be carried out in laboratories. Early in the outbreak, the only labs allowed to do this work were a handful run by Public Health England (PHE). A total of 40 NHS labs were later allowed to process tests and three “mega-labs” are being established, the first of which is now operational in Milton Keynes.
Initially, the government had set a goal of carrying out 10,000 tests per day by the end of March. The UK managed to meet that target slightly late, on April 2. There is now a target of reaching 100,000 tests per day by the end of April; however, the UK only hit 20,000 tests a day for the first time on April 16 and has failed to hit a self-imposed interim target of 25,000 tests a day by mid-April. Many observers think the 100,000 per day target is unachievable.
Last week, Number 10 attempted to shift focus onto the labs performing tests. A spokesperson told The Guardian: “we want the NHS to be making use of any additional capacity which exists” and added “we have to do more in relation to testing”.
However, many of those working in the labs say they simply aren’t being given enough samples to process. A Sky News report revealed that even the new mega-lab in Milton Keynes is running at a fraction of capacity, carrying out 1,500 tests out of a potential 25,000 per day, according to some estimates.
WIRED asked PHE why labs would be under-utilised given the urgency of the present situation, but did not receive a response in time for publication. Health secretary Matt Hancock recently claimed that currently there is “not enough demand” for tests. However, that position sits uncomfortably with statements from Downing Street on the issue, and also with calls to test far more widely, for example in care homes.
So where are the bottlenecks? There have been difficulties, for example, in providing enough swabs to healthcare workers so that they can take samples from patients. At a Number 10 press conference on April 2, Matt Hancock said, “We have fixed the swabs issue”. But not everyone agrees.
“We have never – from the very outset of this – never had a secure supply chain not only for the testing kits but for the swabs as well,” says Allan Wilson, president of the Institute of Biomedical Science (IBMS). “There’s a lab I know in England that had staff in over the [Easter] weekend making DIY swab test kits, because they’d run out.” This DIY work involved making a solution for the swabs to be placed in once a sample is taken, and in which the swabs remain until opened for analysis in a laboratory.
On April 2, Hancock also said the UK had found it hard to compete with countries like Germany (which is performing an estimated 50,000 tests every day) on testing because the UK does not have such a large chemical and diagnostics industry at its disposal.
It’s difficult to untangle that issue from the other realities. Germany pays a higher share of its GDP towards its health service and has Europe’s highest number of critical care beds per capita. In comparison, the UK’s healthcare and diagnostics industries have been underfunded for decades, says Willem van Schaik at the University of Birmingham’s Institute of Microbiology and Infection.
But the problems cannot be merely systemic – other countries that also lack Germany’s resources have performed many more tests per capita compared to the UK. Van Schaik says that he thinks the government “could have done a better job” in preparing for the pandemic in terms of testing.
The problem, some argue, is that the UK failed to pull out all the stops early enough. “I think we were in a pretty good position,” says Sridhar. “But I think what probably wasn’t planned for was the need to ramp up beyond current capacity.”
Expanding testing to more labs sooner, ordering necessary equipment and reagents in time to avoid being stung by shortages – these are just some of the things that those critical of the UK’s approach commonly mention. But there are also questions over how testing is being managed at a national scale, even now. Who decides which lab processes a particular test and why? Who is in charge of distributing samples to ensure lab capacity is being used wisely?
“There seems no coordination of this […] in fact it seems almost uncoordinated,” says Wilson. WIRED spoke to an academic at a UK university whose team has volunteered to help with testing at a nearby PHE lab. The work appeared to be organised purely at a local-level, she said.
Around the UK, the utilisation of testing facilities may depend not so much on central government plans but on whoever happens to be in charge of local labs and staff. “We’ve raided all our laboratories within the university system to source reagents,” says Tony Bjourson at Ulster University. He explains that he is personally involved in organising testing at an NHS lab in the northwest of Northern Ireland, where between 100 and 130 tests per day can be processed.
He says that this should increase fivefold with the arrival of a new DNA purification machine. However, he and colleagues had to raise £112,000 in crowdfunding to source the device – and it isn’t due to arrive for nearly three weeks.
Staff across labs in Northern Ireland are working long hours, sometimes until midnight, to keep up the testing effort, says Bjourson. One colleague hasn’t had a day off in two weeks, he adds. The initiative was taken largely at a regional level, he says, thanks to academic scientists and NHS staff working with the Department of Health in Northern Ireland. But that followed calls from Bjourson to “activate screening and tracking” at a large scale in mid-March after the UK government announced it intended to remove the goal of mass testing.
Bjourson and his colleagues felt they had to take things into their own hands when it came to testing, he suggests. “There was a feeling of that, a feeling of frustration that you maybe see in some of the comments coming out of England where you think, ‘For God’s sake, we’ve got all this skillset…’,” he says.
There are heartening signs that scientists and engineers are doing their best to come up with innovative solutions to the pandemic in the UK. Clearly, lots of people are eager to help – and reasonably well-equipped to do so.
“We’re capable of doing more than 1,000 validation tests a day in our current laboratory – there’s no real technical challenge,” says Thomas Meany at OpenCell, a complex of mini labs built inside 70 shipping containers in London’s Shepherd’s Bush. He adds that PHE would have to accredit the facility in order for him and his colleagues to be able to do such work and, while discussions are ongoing, that hasn’t happened yet.
The UK’s testing problem may, in some part, be tackled at a grass roots level – but getting to that point will take yet longer and relying on a “Dunkirk” approach could be risky, says Wilson. “How do you ensure the quality of those tests coming in from small companies?” he asks.
The irritation being expressed by microbiologists and their colleagues who are critical of the government is not over the quality of labs or people’s willingness to dig in and help. Rather, it is to do with how testing for Covid-19 has been managed, particularly at a national level. As the chances of reaching 100,000 tests per day by the end of April grow ever slimmer, the UK’s sorry predicament is only becoming clearer.
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Updated 20.04.20, 10:20 BST: The original version of the article referred to “viral DNA” being detected by PCR tests. This should have referred to viral RNA, which is then converted to DNA during the PCR process.