Coronavirus (COVID-19) asymptomatic testing programme: evaluation - November 2020 to June 2021

Models of Delivery

What have delivery partners learned about the roll out of testing across pathways and how has that changed over time?

Due to the ever-evolving situation, it is challenging to assess the extent to which the implementation of different models of operation has been successful. Yet, some lessons on how to support and promote the testing programme have been learned. Models of operation are classified below in three main groups, together with the advantages and challenges that have been reported by the delivery partners.

On-site testing

On-site testing was adopted as a model by the University and College pathway over the period of this evaluation. It should be noted that colleges moved in part to home testing from February 2021 and universities moved to community testing over the summer break, with home testing available from the start of the academic year 2021/22. A small minority of healthcare workers also use on-site testing, but the vast majority make use of home testing. Advantages: on-site testing provides the benefit of protecting staff and students, while also enabling continuity with teaching and learning activities.
Challenges: challenges in the University and College pathway model revolved around capacity planning, storage and distribution of test kits, funding to cover costs incurred to set up and run a test centre, complexity surrounding cost recovery, resource and planning challenges due to staff working from home, and legal challenges with data protection. These issues are related to either how test sites have been set up and funded or the ability of universities to plan ahead for the correct amount of resource, utilise hall space for testing, and set up relevant processes under pressure.

Delivery partners in the University & College pathway have also indicated the importance of a demand-led model in their sector, based on comparing student and staff demand, weekly variations in demand (i.e. Fridays are busy with students testing before going home), and increased demand during outbreaks.

The evidence review presented in Annex B reveals how both the costs implied in running similar models (including personnel training and equipment, and use of facilities and services), and time and human costs (in terms of time required to test and report results) have represented a challenge in the implementation of asymptomatic testing programmes in other contexts (pp. 74-75).

Combination of fixed sites and popup and/or mobile options

A network of fixed test sites has been established for asymptomatic people who can both self-administer tests or get a trained helper to support them, with the addition of popup and/or mobile options available for drop-in or booked testing at varying targeted locations depending on need. This combined model has been adopted by many partnerships in Community Testing and in the Prisons pathways.

Advantages: fixed sites create a presence in a local area, advertising the programme to the targeted population. They have been seen as the most appropriate strategy to serve more populated areas, with a pool of trained staff that could be deployed flexibly in response to any increase in cases in the future.

Popup and/or mobile options present the benefit of offering an adaptable and rapid response where most needed, for instance with their deployment to specific places or organisations with an outbreak. When vehicle based mobile units are used, this strategy reduces issues with finding suitable venues.

Delivery partners in the Community Testing pathway report data driven locations for sites and flexible and responsive models of operation as important elements of their testing programme. An alternative model to this combination of fixed sites and popup/mobile units also demonstrates these features: Fire and Rescue Stations, despite being fixed locations, operate on rotation to adapt to where data show particular issues. Suggestions from this pathway to promote flexibility include: offering testing at community based events, targeting holiday spots, and exploring co-location with vaccination centres. A number of the partnerships noted how flexibility will also be key as restrictions ease and many previously used testing venues will return to business as usual.

Challenges: fixed sites are sometimes located where buildings are available and not necessarily where they are most needed, hence leaving some areas without adequate service.

Home testing

Those willing to test at home can either collect the test from their workplace/school or get it delivered at home. This model has been adopted by the Universal Testing, Health and Social Care Workforce, Police Scotland and Scottish Fire and Rescue Service, Highest Risk, Schools and ELC pathways. The University and College Pathway also saw colleges move to home testing in February 2021.

Advantages: home testing represents a convenient, time-effective means of testing.

Data from the YouGov Polling provided by the Universal Offer pathway show that at 4-5 May 60% of respondents (excluding those who said they would not use home testing) expressed a preference for 'self-administered tests ordered online and sent to my home', especially among the youngest age groups.

Challenges: home testing presents a number of challenges according to delivery partners in the Schools and ELC pathways. A lack of encouragement or practical support at home to do the tests for some secondary school pupils was identified by survey respondents as a potential barrier to testing uptake among young people. There was a suggestion from some parents that making on-site testing available at school might help to increase testing uptake.

The tests being uncomfortable or unpleasant was also given as a reason for not continuing with testing by pupils.^[19] The challenges of administering LFD and PCR tests, seen sometimes as invasive and difficult to self-administer, as well as the emotional and physical challenges represented by swabbing younger children and people with disabilities, have also been reported in other UK research. For an examination of these aspects, refer to Annex B (p. 67).

Some delivery partners in the ELC pathway also suggested a greater role for local authorities as a possible improvement. Some representatives from ELC settings suggested that introducing additional staffing resource could better support the administrative delivery of the programme.

Some NHS Boards suggested that in the initial implementation phase they had experienced challenges with LFD ordering, storage, and distribution (these LFDs were then distributed for home use). However, they resolved these issues by creating local LFD kit collection hubs and identifying local service leads, reporting that this was key in implementing the initial phase of LFD testing.

Lessons learned

Some of the lessons learned refer to issues identified in more than one model of operation. In particular:

Data

NHS Boards were clear about the importance of data and access to local data in particular. Having this data allows for planning and supporting targeted work in the local area. This was also mentioned in the Schools and Childcare pathways, where local authority representatives and staff (and parents) wanted information on testing results and trends to better understand the pandemic in their local area and to support their planning.

Communication

The importance of clear and streamlined communication about the reasons why people should get tested and the ways to access and record tests has been underlined by the Community Testing, Schools, and University and College pathways. This perspective is supported by data provided by the Universal Testing pathway showing that at 1-2 June around a fifth (19%) of the YouGov Polling respondents did not understand how regular testing works. Similarly, research conducted in the UK stresses the importance of being clear about the nature and benefits of asymptomatic testing, by promoting awareness of what test results mean, the need to continue testing after being vaccinated or having Covid-19, and different kind of tests and their accuracy. In particular, informing the public of the rationale behind testing frequently (for instance, every 2–4 days) has been deemed key in improving testing uptake. For a discussion of these points, see Annex B (pp. 68-69 and pp. 76-77).

It has been suggested that communications take into account the broad range of test users, especially international students, and explain differences in guidance between Scotland and England (University and College); use a range of media channels and ensure Government websites are more user friendly (Community Testing).

Improvements in communication in a range of areas have also been recommended:

• Some delivery partners in the University & College pathway reported that the information provided (such as staff training packages) were helpful. However, others experienced a delay in the provision of central communication packages which led to institutions having to create their own packages.
• Social Care Workforce survey respondents reported some issues with consistency of information, together with a desire for more information on test accuracy.

Partnership working

Engagement with the community and stakeholders has been indicated as paramount to the successful implementation of the testing programmes. Community Testing has emphasised the importance of building relationships (including those with businesses/employers to encourage staff testing), using outreach teams, employing a community links worker and developing Covid-19 Empowerment Champions to reach non-engaged communities. Collaborative working has been reported as a positive experience by the delivery partners, including the opportunity to meet and work with new people.

Similarly, the University and College pathway reported that liaison and partnership working with other Universities, Public Health and the NHS contributed to the successful implementation of the programme.

These points are also highlighted by a number of UK studies suggesting that involving community leaders and stakeholder organisations in the development and implementation of testing programmes could help build trust, share goals, and bridge cultural and language gaps. Local community leaders and stakeholders have been found to play a fundamental role in determining behaviour change, with local organisations seen as answerable to local people, hence more trustworthy than national, more 'faceless' organisations. These studies are presented in Annex B, pp. 77-78.

Inappropriate use of tests

Clear information is needed about appropriate use of tests. Although evidence is limited, partnerships in the Community Testing pathway suggested there was scope for inappropriate use of LFDs for individuals at increased risk who should be accessing PCR tests instead, such as symptomatic individuals and contacts of confirmed cases. Evidence from the research with the highest risk cohort also confirms this possibility.

The Highest Risk pathway also identified a potential issue with the rollout due to a high likelihood that tests were used beyond the scope of the service: while the aim of the programme was to use the tests for adult household/family members and not those on the highest risk list, 66% of people surveyed said they used the tests themselves.

Complexity impacting footfall

The existence of a number of pathways has been seen as a factor complicating the delivery of the programme. Individuals did not always choose to use the pathway set up for them, which impacted delivery by creating a 'competition' for footfall. The University and College pathway found that administrative staff at the testing centres experienced a decrease in focus as engagement in testing decreased.