The decision to implement a lockdown in Leicester is a mixture of good news and bad. We’re finally seeing a localised approach to the control of coronavirus. But we’re also witnessing the consequences of the government’s mismanaged and disorganised system for detecting outbreaks and dealing with the pandemic.
The national lockdown that was implemented back in March was both necessary and effective. Transmission declined, the epidemic curve was flattened, and hospitals were not overrun. But it was a blunt measure that caused a great deal of collateral damage. Loosening the national lockdown was inevitable. As countries such as South Korea and Germany have shown, a combination of measures – including social distancing, improved hygiene, and an active system for testing, tracing and isolating – can keep the number of coronavirus cases down to a manageable level.
But for this to work, the government’s test, trace and isolate programme would need to be effective. This would mean having much more active case detection than is presently the case, through a greater uptake of testing by the public, and through targeted testing of potentially infected clusters of people identified by primary care providers and local public health teams. This would enable public health teams to detect small outbreaks early, quickly following these up with further investigation. Small outbreaks couldn’t necessarily be prevented, but ideally they could be contained before they grew into larger, uncontrolled outbreaks.
Unfortunately, and somewhat predictably, the government’s over-centralised, fragmented, confused and semi-privatised patchwork of testing and contact-tracing services has proved slow, inadequate and cumbersome. There are still too few tests being done, leading to insufficient case detection, and our contact-tracing rates are also low. Delays in producing test results are compounded by delays and blockages in the sharing of data across the various different organisations involved.
Local public health teams have been inevitably hamstrung by this centralised system. Ideally, local public health directors and their teams would have timely and complete data about new cases, including the names, ages, genders and ethnicities of suspected cases, their home, work and school details, and relevant clinical data such as the date that their symptoms started. But nobody seems to have been given this information. It’s no wonder that 11 days into the reported Leicester outbreak, the health secretary, Matt Hancock, had to concede that the government was “still getting to the bottom of” the reasons why the outbreak had occurred.
The apparent reluctance to share data with local public health teams is worrying. But it’s also curious. What’s the point in collecting data if it isn’t then shared with the people who need it? Moreover, the government appears more concerned with data control than it is with infection control when it comes to local public health teams. And yet it appears to have no qualms about secretly sharing NHS data with private companies through its Covid-19 datastore project. The government only agreed to release some information about its deals with Amazon, Microsoft, Google, Faculty and Palantir after a legal challenge.
It’s equally concerning that the government has been continually unwilling to own up to its faults and mistakes. Hancock’s explanation that “targeted action” at factories, workplaces and schools had been undertaken in Leicester for 10 days prior to the announcement of the lockdown seemed to imply an effective, localised approach. But many local politicians have complained about being unaware of what was happening in Leicester until over a week after the outbreak was first noticed. And by simultaneously announcing a set of new measures for Leicester, including a walk-in test centre in the city, alongside new mobile testing units, Hancock was implicitly admitting that the testing system in Leicesterhad not been up to scratch.
The spin and bluster that have characterised the government’s handling of the pandemic are perhaps as much of a threat to public health as coronavirus itself. Incompetence erodes professional and public trust, which are vital in any effective disease control strategy. If the government doesn’t learn from and fully address these fundamental problems in its response, we should not expect Leicester to be the last city to lock down again in the UK.
For months, public health professionals have been lobbying the government to establish competent and sufficiently resourced local public health teams to help manage the Covid-19 crisis. Such teams could have been hosted by local government public health structures, and been given the mandate to lead on local test, trace and isolate systems, investigate new cases and monitor local behaviour. The teams would include primary care, social care and hospital representatives, and link to regional and national bodies. With their local knowledge, they would draw in the support of the community and voluntary sector, and harness expertise from nearby academic institutions to create the right mix of technical, strategic, organisational and scientific expertise and capacity.
This could have been set up across the country within a matter of weeks. Information systems could similarly have been rapidly designed to feed these teams with accurate, reliable and complete real-time data. A network of contact tracers and community health workers could then have been organised and supervised to take the actions that would have prevented the people of Leicester from suffering the effects of a new local lockdown.
That said, the task facing local authorities should not be underestimated. Local government has been undermined and badly damaged by budget cuts over the last 10 years. Expecting local authorities in places such as Leicester to play this critical role in managing the Covid-19 epidemic, including being effectively responsible for enforcing a localised lockdown, would need central government to not just decentralise resources and authority, but to also better embrace the idea of localism and trust.
• David McCoy is a professor of global public health and director of the Centre for Public Health at Queen Mary University of London