Coronavirus (COVID-19) targeted community testing: national evaluation evidence and insights - final report

1. Introduction

This report summarises evidence and insights at a national level from evaluation of targeted community testing (TCT). The report covers the period 18 January 2021 to 26 September 2021.

Targeted Community Testing Programme

Since January 2021, the Scottish Government have been working in partnership with Public Health Scotland (PHS), local authorities, NHS boards and others to deliver a targeted community testing (TCT) programme for the general public as part of a response to a recognised failure to identify a large proportion of positive COVID-19 cases. TCT is aimed at those without symptoms of coronavirus^[3] and without access to other asymptomatic^[4] testing pathways such as Health and Social Care pathways or Education pathways. It is also aimed at providing symptomatic testing in places people are most likely to be positive.

TCT targets communities/areas where the virus rate is high, quickly rising (spiking), or has been identified as high risk to find positive cases that would not otherwise have been detected. This is to help reduce the spread of the virus in local communities.

The programme provided funding to Local Authority and Health Board partnerships to develop the capabilities to conduct targeted asymptomatic testing; promote the use of data and local intelligence to target testing most appropriately; and enhance isolation and other support for those getting tested. The programme included funding for Scottish Ambulance Service (SAS) operated Mobile Testing Units (MTU) using PCR tests for symptomatic and asymptomatic testing, to expand the fleet and enable targeted placement of these by partnerships. Funding was also provided to the Scottish Environmental Protection Agency (SEPA) and Scottish Water to develop wastewater testing to improve monitoring and detection of virus trends in local areas, adding to the available data and intelligence.

After a pilot of asymptomatic testing with Lateral Flow Tests (LFT) and the targeted deployment of MTUs for symptomatic and asymptomatic testing in November/December 2020^[5], the TCT programme was launched 18 January 2021. It commenced with a number of Health Boards using Scottish Ambulance Service (SAS) operated Mobile Testing Units (MTU) which were deployed, as directed by local partnerships, to target areas to carry out both symptomatic and asymptomatic testing using PCR tests.

From February 11, local partnership-operated asymptomatic only testing sites started to come into operation using Lateral Flow Devices to test (LFT).

Context

It is important to remember that TCT was being implemented at a time when Scotland was in a second full lock-down and the nature of restrictions changed considerably over the time period of the evaluation. Added to this was the roll out of the vaccination programme with increasing numbers being vaccinated week on week. Finally, opportunities for the general public to get tested, regardless of symptom status, were continuously evolving with the advent of the Universal Offer^[6], which launched in Scotland on 26^th April and Pharmacy Collect on 7^th June.

Evaluation

Local partnerships conducted evaluation activities to monitor and inform development of their own individual models of TCT. In addition, evaluation activities were undertaken to inform understanding of TCT from a national perspective and support policy development over time.

An initial evaluation framework and outline plan for how evidence requirements could be met was developed. This was intended to support creation of a national narrative but also provide guidance and consistency of data and evidence capture and use at a local level. Local and national evaluation efforts were further supported through creation of a Local Evaluation Leads Group which met regularly till September 2021. This was used to share experiences, challenges, solutions, approaches and evaluation tools.

The main purpose of this evaluation was to provide timely evidence and insights at a national level to help inform the ongoing development of the programme. Local evaluations were similarly aimed at supporting locally focused ongoing community testing development.

The evaluation objectives set out in the initial evaluation plan were:

1. To understand how best to use data to identify sites for location of targeted community testing

2. To describe what targeted community testing models are put in place and capture key learning from implementation of different models

3. To assess if targeted community testing has encouraged uptake of testing in locations where it is offered

4. To assess if targeted community testing has identified 'hidden' asymptomatic cases

5. To determine if additional support provided by local areas as part of the package of community testing helps with levels of compliance with self-isolation and with non-pharmaceutical interventions (where offered)

6. To understand whether targeted community testing is likely to have supported a reduction in COVID-19 transmission in targeted localities

7. To understand any unintended consequences of targeted community testing, eg increase in risk behaviours/testing fatigue, and including any impact on health inequalities

8. To understand how to support creation of local capacity, resilience and capability to sustain community testing

The scale and rapid pace of development of the programme through multiple evolutions, combined with challenges around answering some of the original research questions, led to a focus for the national evaluation on objectives 3 and 4, ie case identification, qualitative understanding of features of successful targeting and uptake, including public motivations and barriers. Some data and qualitative evidence were also captured on models and delivery.

A range of the other objectives were met in a more timely fashion and in more depth using active learning via groups such as a Reference Group; Short Life Data Working Group and Mobile Testing Working Group, as well as through regular meetings between policy and partnerships, and partnership to partnership direct engagement. The evidence and learning via these processes has not been formally captured. Further information on the groups listed is available in Annex A.

Key findings have been shared via regularly updated summary slide sets circulated to the Community Testing Programme Board, Reference Group and Local Evaluation Leads Group; a briefing note on early operational learning, and a number of presentations on the evidence. This report draws this evidence together, including an update on data to 26 September 2021.

The data: quality and caveats

The national evaluation has drawn mainly on published PHS data, alongside primary qualitative research with partnerships.

PHS published TCT relevant data weekly in their COVID-19 Statistical Report and on an accompanying interactive TCT dashboard. This included the number of symptomatic and asymptomatic tests conducted and cases found by TCT MTU testing, and asymptomatic tests conducted and cases found by community asymptomatic testing using LFTs^[7].

It is important to note that the data referred to above was not created for the purposes of evaluation. This was mainly operational data. Data has not been available for all measures desired and assumptions have often being drawn from incomplete data or data that does not measure exactly what needed to be assessed. Qualitative data is not nationally representative. Further considerations around data quality are highlighted, where relevant, in the findings sections.

Demographic data has been limited, so detailed information on who has been testing where and when was not available. This means partial understanding of how TCT has been used by different groups in terms of the protected characteristics and socio-economic status. To address this issue, at least in part, qualitative evidence on uptake as well as a number of the other research objectives was collected from partnerships at two time points. This information was collected using two different styles of Proforma – a framework setting out the types of information and evidence sought.

The first Proforma was distributed mid-March 2021 to 7 of the partnerships who were already underway with their proposals. All 7 submitted by the end of March, 10 weeks after launch. The second was distributed mid-May to 11 of the partnerships, with 8 submitted by the end of May 2021 to coincide with a review of the wider asymptomatic testing strategy.

In a similar way to an organisational response to a consultation exercise, Proforma responses were at the organisational level and generally required input from different people involved in the local partnership TCT, including different local authority partners, to provide a signed off partnership response. The submitted Proformas varied widely in the detail provided. Both Proforma templates are presented in Annex B.