This paper draws on a subset of 24 interviews discussing testing from 13 participants (five scientific advisors and eight HCWs). The scientists were advising the UK Government on COVID-19 response, the need for anonymity prevents further description. The HCWs were drawn from NHS primary and secondary care settings and included nurses, a dietitian, a speech and language therapist, two doctors who were both departmental clinical directors and a GP partner. Two interviewees were interviewed once, the remainder, between two and five times each (March-August 2020). We identified two major cross-cutting themes: perceptions on testing strategies and implications; and policy implementation.
Perceptions on testing strategies and implications
Scientific advisors and HCWs discussed the benefits, challenges and implications of results from different types of COVID-19 test. The HCWs were broadly positive about the role of RT-PCR and antibody testing in HCWs, both to identify current infection (RT-PCR testing) and thus avoid passing it to patients, other staff or those at home though isolation, and to provide clarity about a person’s previous COVID-19 exposure (antibody testing). However, concerns about the limitations of RT-PCR test results were raised, including accuracy, the limited period of the test’s relevance, lack of clarity about whether a HCW was infectious, and the implications of a positive test result.
“…the PCR test just detects the genetic material, it doesn’t tell you if the virus is viable…people can be PCR positive for a very long time so it’s causing difficulties in people returning to work, particularly health care workers, when they are PCR positive, but they are well, does that mean they are still infectious? Sometimes people are antibody positive and PCR positive so how do you interpret that?” (Scientific advisor 4 2.7.20).
Speaking about their involvement with a research project exploring COVID infection rates through RT-PCR testing, one GP who was also a Clinical director of a primary care network (PCN) was concerned about the organisational implications of a positive test result
“…we might lose a third of our staff overnight because they might be positive…and that’s an ethical dilemma…so they test this week, but then what happens next week...so the risk is, it’s continual. It’s not something that was resolved by the testing” (19.5.20).
The findings illustrate some tensions arising from the ongoing need to manage COVID related health risks and maintain health service provision with a reduced staffing complement. As the following quotes illustrate some HCWs perceived that antibody testing may address some of these difficulties, providing confirmation of previous infection with COVID-19,
“…you’re a health care professional working with Covid patients, you’ve had an antibody test…I think people would be reassured to know whether they had it or not, not just a swab at the time, because it means nothing, really, because I could be swabbed on a Tuesday and then I could actually have it that afternoon…” (Respiratory nurse ITU 11.5.20).
Another nurse reported “feeling somehow protected” in spite of an uncertain length of immunity and that a positive antibody result had given her “a bit of peace of mind” as she felt she was not spreading the virus (Specialist nurse ITU 11.6.20), while a clinical director stated, “I’d also quite like to be positive to know that I’ve got an immune response” (3.6.20). However, the idea that a HCW would be immune from COVID following infection was questioned, illustrating variations in perceptions of virus transmission and risk
“…we have no idea whether detection of antibodies will be protective in a year’s time” (Scientific advisor 2 17.3.20).
“I have heard so many doctors, even infectious diseases consultants sort of confidently say ‘I’m immune because I have got antibody’ and we just don’t know that” (Scientific advisor 2 5.6.20).
Though not widely available during wave one, participants from both cohorts spoke of the positive value of having end of infectiousness testing. In March 2020 one scientific advisor spoke of the tension between its utility and limited availability.
“In an ideal world we would have laboratory confirmation to say ‘you are no longer infectious’, or ‘we think it’s highly unlikely that you’re infectious’. That applies to discharge home as well, but we don’t have enough laboratory tests to do end of illness testing” (Scientific advisor 2 27.3.20).
Similarly, though a hospital-based dietitian reported following the guidance and returning to work seven days after COVID-19, she was concerned about her unknown status and potential capacity to infect.
“When I came back after a week of Covid, my family, like all my friends…they were like ‘you are joking? You are coming back to work without a negative swab?’...and I’m like ‘yeah, that’s the rule, I’m going back to work’…I was so careful in the department” (Registered dietician 14.5.20).
In summary, the findings highlight doubts about whether RT-PCR and antibody tests were fit for purpose in relation to their policy goals, for example returning HCWs to work with the certainty they were not infectious.
Policy implementation
At the national level two advisors were concerned about the lack of an integrated outbreak approach in the summer of 2020; in this case the lifting of lockdown restrictions before a fully functioning test, trace and isolate system had been operationalised as this quote illustrates:
“…no other country has tried to lift restrictions when it has had ten thousand new cases a day and an R0 of 0.7-1. And to have done so in a relatively haphazard way with some confused messages and therefore some confused outcomes…and as a result of that, there is now a higher risk that we will get a rebound…at the same time as you start to have the Autumn respiratory infections as well”(Scientific advisor 3 3.6.20).
Concerns about the emergence of a second wave were realised in the latter half of 2020 [29].
At the local level concerns were expressed about a lack of consideration given to the implementation and implications of national NHS staff antibody testing roll out. This policy initiative was communicated in a letter (25.5.20) from NHS England and NHS Improvement to regional NHS directors, NHS trusts, and primary care organisations. A hospital based clinical director responsible for writing standard operating staff testing procedures raised questions about who should get the test results.
“does it go to your GP? Does it go to occupational health or… does it go purely to the individual?” (Clinical director 3.6.20).
Similarly a GP Clinical director of a primary care network raised the question of personal versus organizational responsibility for risk management and expressed some uncertainties about what the results would mean in practice.
“whose responsibility is it to give them the results? What does that mean? How do you counsel them? Needs to be sorted out before you then just go and blanket test everyone” (2.6.20).
The gap between testing advice, policy and implementation and its implications for outbreak management was also noted by one of the advisors:
”it isn’t about the advice, it is all about the implementation and implementation is difficult, reaching out to every MP, every hospital, every manufacturer is not easy…but there has been too much of a separation of advice, lag phase, implementation and we can’t get that wrong…otherwise we will go very quickly back into a rebound” (Scientific advisor 3 17.4.20).
Finally, HCWs having to isolate following a positive test result noted some difficulties when working remotely. Challenges included accessing work electronically, particularly patient files, and feelings of guilt for contacting work-based colleagues as teams were running at reduced capacity.
“for 14 days I had to work from home without remote access. So I only had access to my emails, I couldn’t get remote access to the electronic medical records system, so I had to do telephone reviews or do anything to help the team in the hospital…I was feeling bad being at home, pestering my colleagues” (Registered dietician 14.5.20).
Challenges to accessing RT-PCR tests were also noted in some settings, with significant delays for those that were delivered to homes (rather than attending testing centres) meaning HCW were unsure if they were positive for COVID-19, and unclear on whether they should isolate or could return to work. Speaking about a colleague, one nurse reported a slow testing process:
“…she had to wait for the kit to be sent to her and then she had to send it back and wait for the result so that takes pretty much over a week until the test came back COVID positive” (Specialist nurse ITU 24.7.20).
In summary, the data has illustrated that national testing policies were not sensitised to local realities.