Alongside a vaccine, there has been one great white hope at the heart of the government’s Covid-19 strategy for some months.
That hope is mass testing. Variously the concept has been announced as whole-town testing, whole-city testing – such as the trial currently ongoing in Liverpool – and, most strikingly, as the ‘moonshot’: an ambitious attempt to achieve the almost-impossible, a definition that has not stopped ministers from repeatedly presenting it as their core and flagship pandemic response.
The testing ‘moonshot’ could be a way of moving back towards normal life by testing millions of asymptomatic people through new, rapid technology, the government has said, particularly if there is a problem or hold-up on any vaccine.
Liverpool’s trial, which began the Friday before last, has been the latest high-profile iteration of that strategy.
Boris Johnson hailed the pilot – which has seen everyone in the city offered rapid tests, carried out by the army – as having ‘the potential to be a powerful new weapon in our fight against Covid-19’.
But down the M62 in Greater Manchester, the latest blaze of publicity around mass testing was met with caution. Not because the system here thinks Liverpool shouldn’t have participated in the trial, say insiders, but because they believe the devil is in the detail – and they want to exercise some control over the way mass testing is applied here.
A locally-designed approach is now starting to take shape, but it isn’t likely to mean every one of the 2.8m people living here gets offered a pregnancy-style Covid test any time soon. Despite the rhetoric, there is far from consensus over how well the available tests work, how they should be used, or on what scale.
Greater Manchester has arguably already had its fingers burnt once on mass testing. Salford’s own ‘moonshot’, a trial that was itself announced to fanfare less than two months before the Liverpool pilot, was in reality a very initial pilot of new technology. At the time the government’s Chief Scientific Adviser Sir Patrick Vallance noted of mass testing that ‘we would be completely wrong to assume this is a slam dunk that can definitely happen’, although it was hailed as a ‘freedom pass’ by the government.
“Crucially, it should be possible to deploy these tests on a far bigger scale than any country has yet achieved – literally millions of tests processed every single day,” the Prime Minister told journalists during the Downing Street press conference on September 9.
Public updates on the Salford trial have been notably elusive ever since. But multiple insiders say that from the word go, Salford council struggled to get any assurances over the quality of the tech it had been given, known as ‘LAMP’ tests – emerging technology intended to turn around a saliva sample in a lab within a couple of hours. It was an issue later raised by the city’s MP Rebecca Long Bailey in Parliament.
“Salford was to be one of the pilot areas testing this ‘moonshot’ programme’,” she said on October 13.
“However, my local council confirmed to me this morning that, some time ago now, it asked the Department of Health and Social Care to share the clinical validity data behind this new technology. To date, that query remains unanswered, and until this morning Salford city council had been told to pause the programme.”
The Department of Health and Social Care has been approached for comment on why that data had not been provided to Salford council at the time, but no response has been received.
By early November, Greater Manchester’s Mass Testing Expert Group – which isn’t running the Salford trial, but has been assessing all the evidence available in order to draw up a strategy for the region – had written to ministers warning that, according to the initial Salford results, the LAMP tests were less than 50pc effective.
Government was not happy. Two other trials, elsewhere in the country, had shown the tests to be around 90pc effective.
According to one senior figure with knowledge of Greater Manchester’s emerging mass testing strategy, government scientists believed Salford had not been strict enough about the conditions under which the tests were processed – whereas experts here believed that there was little point making rigid clinical laboratory assumptions about a test that, if it was to be truly used on a mass scale, needed to be trialled as though a member of the public was using them.
“Manchester testers said: this is real-world testing that you want to do on the streets of Manchester,” they said. “It doesn’t matter if you get it working in a lab. Our scientists believe attaining lab perfection negates the point of the trial. Could you scale to 100,000 a day?”
Amid a stand-off between local and government scientists, Salford has now agreed to do the pilot again.
There had been some ‘discrepancies’ between trials in different parts of the country, admitted Andy Burnham last week, adding that the Salford trial is to be ‘re-run’. It is understood Salford has agreed to test around 3,000 further people using the LAMP tests.
A senior official involved in mass testing is blunt.
“We have made a decision to tug the forelock and look at LAMP again,” they said, but added that Greater Manchester was still ‘holding back on scaling this up’. The view here remains that LAMP tests are not the answer.
So that was the backdrop against which government announced another ‘moonshot’ testing trial for the start of November, this time in Liverpool.
Liverpool’s pilot was to use a different type of technology for the bulk of its pilot: ‘lateral flow’, which uses a pregnancy-style test to analyse a swab sample from the back of the nose and throat, with results available within half an hour without the need for a lab process.
The city was given the logistical muscle of 2,000 soldiers to offer those tests to all its residents, as well as targeting specific groups of people.
Greater Manchester expressed caution, both privately and publicly.
“There’s questions about logistics, there’s questions around the tests used, there’s questions around how the public will respond to it,” said Manchester’s health lead Bev Craig when asked about the Liverpool trial’s implications for Manchester a couple of days before it began, summing up the view of many in the system at the time.
“Because I think on the whole it is a good thing – but it’s a good thing when it’s part of something bigger.” In other words, mass testing had to sit within a wider strategy, one that took into account human behaviour, incentives for self isolation and the reality of both logistical resources and contact tracing.
Since then, the results of the Liverpool trial have begun to filter through.
As of the back end of last week, the mass pilot had reached around 16pc of the city’s population. Perspectives on that are mixed: on the one hand, Liverpool’s trial is collecting a solid evidence base on the tests that hadn’t been there previously – in the words of more than one public health official, the city is ‘taking one for the team’ more widely, by being the area that shows what does and doesn’t work.
It is also pinpointing hundreds of asymptomatic cases that would not have otherwise been identified.
Nevertheless that percentage does contain a large proportion of ‘worried well’ coming forward for tests, or what health people call the ‘inverse care law’: those who least need them – because they are at least risk of having picked up the virus – are the ones requesting them. That is potentially also reflected in the low positivity rates from the trial too, at around 0.6pc.
The lateral flow tests themselves, meanwhile, have also prompted fierce debate within the health and science communities.
Susan Hopkins, Chief Medical Adviser for the national test and trace system, said on Friday that the tests are ‘proving to be accurate and reliable’. But there is less consensus on that point than her comments would suggest.
Government’s trial data on the tests, released last week, shows that 77pc of positive cases are identified first time – described as ‘good, but not great’ by one senior official here – when carried out by health professionals. But that drops to around 58pc when carried out by members of the public themselves.
In effect, that means the tests are very good at picking up people who are highly infectious, but not so good at detecting those in the first stages of having the virus. Professor John Deeks, a biostatistician at Birmingham University, has been among those warning that that’s a problem.
A negative result from a lateral flow test should be viewed as a ‘risk reduction’, he believes, and not proof that the person in question does not have it.
“You still have to think you’ve potentially got it,” he added of people using the tests.
Meanwhile the government’s announcement – just four days into the Liverpool trial – that it would be rolling out thousands of the tests to 66 more local authorities was met with a mixed reception.
Sheffield’s director of public health, Greg Fell, told BBC Newsnight on Friday: “The point of pilots is to learn from pilots. So it’s probably a bit premature to be pushing on rolling this out in spaces at other places before we know the results of the pilot study.”
There are plenty within the Greater Manchester system who agree with Fell’s analysis. One senior health official here says his take is ‘right’, while a second calls him ‘a rock star to us all – he is also exact and precise’.
Nevertheless the conurbation has put up its hand for the roll-out on a pragmatic basis, because it believes the tests could have their uses, even if that must be in a focused and limited way rather than on the scale ministers have tended to imply.
“Everything is imperfect, but the one you can use the best is lateral flow,” says one senior health figure here of the tests available, arguing that while they aren’t as effective as the slower turnaround tests we are used to, they do catch medium and high-risk spreaders of the virus.
A second senior figure says in their view the lateral flow tests are ‘usable’.
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Another says they agree with Greg Fell that Liverpool’s pilot should not have been rolled out before it’s finished. But if offered the tests, they will give it a go.
“We’ll do it in a strategic, targeted way that gets best application of the technology, whilst recognising and mitigating for its limitations,” they said.
Similarly at last week’s mayoral press conference, Andy Burnham conceded there are ‘concerns’ about the lateral flow roll-out, ‘but not so much that we think this is the wrong thing to do’.
Those worries do include the role of the contact tracing system, he confirmed, as well as the fear that any area taking up such a trial could get ‘trapped’ in a higher lockdown tier as a result of a rise in cases.
But while ‘the detail is being worked through’, he said, the government’s latest approach to the roll-out gave reason to be hopeful – because it suggested Greater Manchester might be able to do things its own way.
“A letter was sent out by the government this week offering a variation on the Liverpool approach, which would be to offer mass testing for around 10pc of local populations, and that being decided more locally.
“I think that landed pretty well – I think people can see the merits of that approach.”
A webinar held by the health secretary Matt Hancock last Friday with local authorities also seemed to inspire optimism.
“We have permission to do it our way…hurrah,” said one figure afterwards. “GM mass testing strategy it is then.”
So unlike the Salford trial – or the Liverpool one – it appears the conurbation will indeed have the opportunity to design its use of the tests itself. That’s not a position unique to Greater Manchester, but an approach now seemingly being taken where all local authorities involved in the lateral flow roll-out are concerned.
In Manchester, said one senior town hall figure, there is already the outline of a plan.
“If you look at the city of Manchester, the three priorities are health and care staff, students and potentially visitors to care homes. After that, it’s probably schools,” they said, adding that Matt Hancock had made clear ‘it’s up to you’.
Another said Liverpool’s data ‘appears to support [the assumption] that lateral flow are good at high risk of transmission cases’, so therefore potentially have a key use in the repeat testing of healthcare workers – who also, crucially, are trained enough to use them more effectively. That way you can at least ‘break the chain’ where the most infectious staff are concerned, they note.
Nevertheless where the debate is particularly live, including in Greater Manchester, is whether they are suitable for care home visitors. While Andy Burnham suggested last week – and is not alone in suggesting – that they could be, others are more nervous.
“I completely understand people want to visit care homes,” says one senior council figure, but notes that there’s still ‘a lot of questions in terms of what the sciences says’ on lateral flow ‘and what it could mean in practice’.
“I’m not sure the most vulnerable should be a petri dish. So if there are any questions around how this works and is administered, it’s not that it won’t be used in them, but it maybe shouldn’t be used in them first.”
The debate on mass testing within Greater Manchester will therefore continue in earnest, as scientists on the region’s advisory committee, public health directors and politicians all thrash out the risks and benefits of what is a new technology.
Questions remain, including the pressure on the contact tracing system of a flood in new cases, the level of logistics required – given that the army is not about to be deployed to all 66 local authorities trialling lateral flow tests – and precisely where the testing will be best used. But many believe there has at least been progress: the latest trials could now be done according to the needs on the ground, rather than the pace of the news cycle.
In between the rhetoric and the reality lies a great morass of scientific debate, emerging technology and local nuance. As one official notes, such trials should be done ‘as a public health pilot, not a political one’.
“Greater Manchester wants to do things their way,” concludes another. “Even if asking any questions of this government puts you on the naughty step.”