Test and Trace in England – Progress Update — UK National Audit Office, HC 295 (June 2021)

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SESSION 2021-22
25 JUNE 2021
HC 295
REPORT
by the Comptroller 
and Auditor General
Test and trace in England – 
progress update
Department of Health & Social Care

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Gareth Davies 
Comptroller and Auditor General 
National Audit Office
21 June 2021
HC 295  |  £10.00
Test and trace in England – 
progress update
Department of Health & Social Care

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© National Audit Office 2021

Contents
Key facts  4
Summary  5
Part One
Update on the government’s test 
and trace approach in England  16
Part Two
Funding and spending 
for test and trace  32
Part Three
Performance and effectiveness 
of test and trace  48
Part Four
Future plans for the NHS 
Test and Trace Service  69
Appendix One
Our audit approach  76
Appendix Two
Our evidence base  79
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The National Audit Office study 
team consisted of:
Muhammad Bhayat, 
Rosie Buckley, Alice Kitchen, 
Francis Lind, Natalie Low, 
Eleanor Murray, Tunmise Usikalu, 
Freddie Wong, David Xu, 
under the direction of 
Robert White. 
This report can be found on the 
National Audit Office website at 
www.nao.org.uk
If you need a version of this 
report in an alternative format 
for accessibility reasons, or 
any of the figures in a different 
format, contact the NAO at 
enquiries@nao.org.uk
For further information about the 
National Audit Office please contact:
National Audit Office 
Press Office 
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4  Key facts  Test and trace in England – progress update
Key facts
£13.5bn 
expenditure by NHS Test and 
Trace Service (NHST&T) in 
2020-21, compared with a 
budget of £22.2 billion
964
contracts, worth £14.1 billion, 
let to public and private 
organisations for suppliers, 
services and infrastructure 
to support test and trace 
services in 2020-21 
102m
number of NHST&T tests done 
in community settings between 
November 2020 and April 2021, 
the majority of which, 69 million, 
were rapid-result lateral fl ow 
device (LFD) tests, rolled out 
from October 2020
90%
proportion of those tested in person in the community (under Pillar 2 of 
the testing system) who received their PCR results within 24 hours, for 
the last week of April 2021, up from 38% in the last week of October 
2020 and a low of 17% during December 2020
84% – 94% 
the proportion of close contacts of people testing positive for 
COVID-19 that NHST&T reports having reached and advised to 
self-isolate, which was achieved for each week starting from 
3 December 2020 to 29 April 2021. In May 2020, the Scientifi c 
Advisory Group for Emergencies advised that an effective test 
and trace system should reach at least 80% of close contacts 
of index cases
45% 
average utilisation rate for NHST&T laboratories between 
November 2020 and April 2021 compared with NHST&T’s safe 
utilisation threshold of 80%
11% – 49%
range of daily utilisation rates for NHST&T telephone tracers and 
contact centre staff between November 2020 and May 2021, 
compared with an average utilisation rate target of 50% 
November 
2020
the last month that NHST&T was able to calculate its key 
performance indicator for the percentage of new infections it 
identifi es through its testing. In December the Offi ce for National 
Statistics paused publication of the estimates it was based on, 
for methodological reasons
14%
the percentage of lateral fl ow tests registered as used by 
26 May 2021. NHST&T had distributed 691 million tests and 
results had been recorded for 96 million of them

Test and trace in England – progress update  Summary  5 
Summary
Introduction
1	
This is the second of our reports on government’s approach to test and trace 
services in England and it covers the period from the beginning of November 2020. 
It follows a December 2020 interim publication, which reported on NHS Test and 
Trace (NHST&T) from its creation in May 2020 until October 2020.
2	
Between the start of the COVID-19 pandemic and the end of April 2021 
there have been over 4 million confirmed infections and 131,600 deaths involving 
COVID-19 in England. Test and trace services are designed to play a core role 
in government’s response to the pandemic, which has also included restrictions 
on social contact, travel, retail, workplaces and educational establishments, and 
from December 2020 the roll-out of the vaccination programme. Test and trace 
programmes for COVID-19 aim to reduce infections by identifying individuals with 
the virus, tracing their contacts and isolating them to limit further transmission.
3	
NHST&T, part of the Department of Health & Social Care (the Department), 
was created on 28 May 2020 to lead on the government’s test, trace and contain 
approach. Its overall purpose is to “help break chains of COVID-19 transmission and 
enable people to return to a more normal way of life”. NHST&T works in conjunction 
with Public Health England (PHE), local authorities, and commercial and academic 
providers. Together, they provide:
•	
testing services, through a combination of testing sites and home testing, 
that include PCR (polymerase chain reaction) tests for people with symptoms, 
which are processed by laboratories, and regular asymptomatic testing for 
communities, workplaces, education, health and social care settings and the 
wider public mostly using LFD (lateral flow device) tests that do not require 
laboratory processing;
•	
laboratories to process PCR results and identify and track new variants using 
genomic sequencing;
•	
tracing services to trace people who test positive and their contacts and 
providing a legal instruction for them to self-isolate;
•	
support to people self-isolating, including financial support and other 
practical assistance; and
•	
Research, data analysis and insight to support local and national 
decision‑making through the Joint Biosecurity Centre.

6  Summary  Test and trace in England – progress update
4	
The government published the COVID-19 Winter Plan on 23 November 2020, 
setting out plans to tackle the next stage of the pandemic. NHST&T has been 
responsible, with its partners, for delivering many of these including the introduction 
of mass asymptomatic testing and closer working with local authorities.
5	
On 24 March 2021, the government announced that NHST&T would form part 
of the newly created UK Health Security Agency (UKHSA). This transition is intended 
to complete by the end of October 2021. NHST&T and UKHSA will therefore be 
implementing these structural changes, alongside leading test and trace as part 
of government’s ongoing COVID-19 response.
Scope of this report
6	
This second report provides an update, focusing on the period from 
November 2020 to April 2021. It is factual and does not present a full 
value‑for‑money assessment. This reflects the time period covered and the 
changing and ongoing response to the pandemic. The report covers:
•	
major developments in the test, trace and isolate programme from 
November 2020 (Part One);
•	
funding and spending for the programme in 2020-21, including its use 
of contracts, consultants and its utilisation rates (Part Two);
•	
the performance and effectiveness of test and trace services up to the 
end of April 2021 (Part Three); and
•	
current plans for the future delivery of test and trace services, including 
transition arrangements to the new UKHSA, and securing a longer-term 
benefit from the investment into test and trace services (Part Four).

Test and trace in England – progress update  Summary  7 
Key findings
Developments in test and trace from November 2020
7	
NHST&T significantly increased its testing and tracing capacity and activity 
to manage the surge in infections in December 2020 and continues to operate 
in an environment of uncertain and fluctuating demand for its services. Levels of 
COVID-19 infections rose sharply between the end of November 2020 and the 
end of December 2020, resulting in more demand for testing and tracing services. 
Between the end of November 2020 and the end of December 2020, the number 
of people tested by NHST&T increased by more than 50%, and tracing activity more 
than quadrupled. NHST&T expanded the total theoretical processing capacity for 
PCR tests from 500,000 per day at the end of October to 800,000 by January 2021. 
NHST&T is working in a very uncertain environment where it is difficult to make 
predictions about the future prevalence of COVID-19 and the resulting demand 
on testing and tracing. NHST&T, working with departments across government, 
had to set up a testing service for hauliers at very short notice over Christmas 
2020. Stakeholders told us that they were very satisfied with how the service was 
implemented (paragraphs 1.7, 1.10, 1.11, 2.15, 3.5, 3.7, 3.10, 4.1, 4.6 and 4.7).
8	
NHST&T has rolled out regular asymptomatic testing, using rapid-result LFD 
tests, to try to identify cases of COVID-19 among people without symptoms. Only a 
small proportion of the tests distributed have been registered as used. LFD tests 
provide much faster results in detecting COVID-19 than laboratory-processed PCR 
tests but are less likely to detect the virus at the beginning or end of an infection. 
Asymptomatic testing was initially targeted at more vulnerable groups (for example, 
care home residents) or where infection levels were likely to be higher. Eligibility has 
since been expanded so that the whole population of England is eligible for two LFD 
tests each week. NHST&T forecast that between 1 March and 30 May 2021, 655 
million tests would be used in the UK. However, by 26 May, of the 691 million tests 
it has distributed in England, only 96 million (14%) had been registered as used. 
Of tests not yet registered, it is not possible for NHST&T to know how many tests 
have been used or not. NHST&T has now started research to understand why the 
registration of test results is so low (paragraphs 1.12 to 1.16, 2.18 and 2.19).

8  Summary  Test and trace in England – progress update
9	
NHST&T has developed a programme of work to identify and contain variant 
forms of COVID-19, and currently screens all viable positive PCR tests for variants. 
It has made an important contribution to international efforts to track new variants. 
Variant forms of COVID-19 may pose different levels of risk in terms of the 
transmission or severity of illness. NHST&T has developed a strategy to identify and 
contain variants. It screens all viable positive PCR tests for variants (not all tests 
contain enough material to allow screening to take place) and by April 2021 had 
worked with local authorities to carry out surge testing in 39 areas of England where 
cases of variants have been identified. NHST&T also provides testing and tracing 
services in support of border controls, aiming to minimise the entry of new variants 
to the country. The UK has made a very significant contribution to international 
understanding of variants: about 30% of genomic sequencing results shared 
internationally come from the UK, making it the largest single contributor. Samples 
are collected by NHST&T and processed by the COVID-19 Genomics Consortium, 
Wellcome Sanger Institute and the public health agencies of the four nations 
(paragraphs 1.18 to 1.24).
10	
Local authorities’ involvement in testing and tracing has increased significantly 
in line with NHST&T’s December Business Plan commitment, but challenges to 
effective partnership working remain. The Business Plan set out an ambition for 
NHST&T to strengthen its partnerships with local authorities, including through 
expanding their role in testing and tracing. Nearly all local authorities now run their 
own contact tracing schemes for harder to reach cases, and some areas are piloting 
taking on all contact tracing. Local stakeholders reported that NHST&T’s data 
sharing and engagement with local authorities has improved, but that they and other 
partners (for example, home care providers) cannot yet access all the information 
they need when they need it. NHST&T continues to work to improve access to data 
for local authorities and now provides data on positive test results including detailed 
demographic and other information for positive cases. It has recognised the need to 
continue to develop its approach to share data faster, more widely and more easily, 
with local authorities and others (paragraphs 1.16, 1.22, 1.23, and 1.25 to 1.28).

Test and trace in England – progress update  Summary  9 
Update on test and trace spending and contracts
11	
Based on unaudited data, NHST&T spent £13.5 billion out of a £22.2 billion 
budget in 2020-21, an underspend of £8.7 billion (39%). Of this, NHST&T spent 
£10.4 billion on testing (77% of total spending), £1.8 billion on ‘contain’ activities 
(to identify local COVID-19 outbreaks and support local responses to the pandemic, 
13% of total spending), and £0.9 billion on tracing activities (7% of total spending). 
Of this 2020-21 spend, it paid out local authority grants of £2.2 billion, primarily for 
‘contain’ activities. NHST&T underspent its budget by £8.7 billion, or 39%, primarily 
in testing, specifically asymptomatic LFD testing, and laboratories and associated 
costs (£7.9 billion, 91% of the underspend). NHST&T told us this is because the 
high level of demand for testing forecast for January and February 2021 did not 
materialise, in part due to national lockdown measures. The roll-out of mass testing 
was delayed from January to March, and eventual uptake was much lower than 
expected, which also contributed to the underspend. Savings from price reductions 
and renegotiations on committed volumes and projects also contributed to some 
£2.2 billion of the underspend. The National Audit Office is currently undertaking the 
2020-21 financial audit of the Department, which includes NHST&T. The Department 
expects to publish its audited accounts later in 2021 (paragraphs 2.1 to 2.4).
12	
NHST&T has introduced more flexibility into its contracts but with average 
utilisation rates of its testing and tracing capacities remaining low, it is paying for 
capacity it does not use, and is still using emergency measures to procure without 
competition. Since November 2020, NHST&T has built more flexibility into its contact 
centre contracts to allow it to adjust capacity, and from September 2021 it plans 
to use staff more flexibly across different services. Between November 2020 and 
May 2021, the utilisation rate for its contact tracers and other contact centre staff 
(the percentage of paid time they spent working) has generally remained well below 
the 50% target, peaking at 49% in January 2021 and falling to around 11% in 
February. For its laboratory testing facilities, it does not have a target utilisation rate 
but sets a threshold of 80% beyond which a laboratory does not operate safely 
or reliably; the average utilisation rate was 45% between November 2020 and 
April 2021. NHST&T awarded fewer contracts using emergency regulations in the 
period January to March 2021 than in April to June 2020. However, the value of the 
contracts awarded under emergency regulations more than doubled from £1.1 billion 
(April to June 2020) to £2.6 billion (January to March 2021). The largest contract 
NHST&T awarded using emergency powers in January to March 2021 was for 
LFDs for self-tests (£1.9 billion). NHST&T told us that only one supplier had secured 
regulatory approval to supply these tests, so it was not possible to run a competition. 
The absence of competition and normal regulatory processes brings risks to value 
for money (paragraphs 2.8 to 2.11, and 2.14 to 2.17, Figure 13).

10  Summary  Test and trace in England – progress update
13	
NHST&T continues to rely heavily on consultancy support. NHST&T relied on 
management consultancy to staff up its organisation quickly. In November 2020, 
NHST&T outlined plans to reduce the number of consultants it employed. However, 
it employed more consultants in April 2021 (2,239) than in December 2020 (2,164), 
and as at mid-April, consultants still accounted for 45% of NHST&T’s central staff. 
NHST&T told us that reducing its use of consultants has been made more difficult 
because of skills shortages in certain areas in the civil service, uncertainties 
with the transition to UKHSA and comparatively low salaries in the civil service 
(paragraphs 2.20 to 2.23).
Overall performance and effectiveness of test and trace
14	
While NHST&T’s performance against operational targets generally improved 
between the end of October 2020 and April 2021, it fell well below target when 
cases rose sharply in December. NHST&T provided results for 90% of PCR 
tests taken in person in the community within 24 hours at the end of April 2021. 
This was up from 38% at the end of October 2020, and a low of 17% during 
December. NHST&T also met targets for the overall proportion it reaches of 
people testing positive (90%) in mid-March 2021, and of identified contacts 
(85%) from the start of December 2020. However, performance slipped a little 
below both targets during April. In April 2021, NHST&T reached 81% of people 
who had tested positive for COVID-19 within 24 hours compared with 72% at 
the end of October 2020 (paragraphs 3.6 and 3.8 to 3.11).
15	
NHST&T has reduced the time taken between a test being booked and contacts 
being traced, a key measure of system effectiveness, for in-person PCR tests. It is 
less clear whether the wider system is operating as quickly as it needs to be fully 
effective. The UK Scientific Advisory Group for Emergencies (SAGE) advises that, 
for test and trace to be effective, it is desirable that no more than 48 hours should 
elapse between identification of an index case and their contacts self-isolating. 
NHST&T has interpreted this as the time between booking a test and contacts 
being reached, and initially set itself a target for this to be within 72 hours in 80% 
of cases, subsequently revising that to within 48 hours. NHST&T met the 72‑hour 
target for in-person PCR tests from January 2021 onwards, and the 48‑hour 
target during March 2021. In-person PCR tests represent a declining minority of 
tests (37% over the period May 2020 to April 2021, 16% of PCR tests in March 
and April 2021). NHST&T does not have an equivalent timeliness target for other 
PCR tests, for example home test kits or tests supplied to care homes for regular 
testing of staff and residents. We have also examined wider timeliness of all PCR 
tests from the point of symptom onset (before booking a test) to an individual 
contact being reached. SAGE has not offered a view on this, but other international 
evidence suggests a timeframe of not more than 48 – 72 hours. The median time 
between a case developing symptoms and an individual contact being reached 
for all PCR tests from people with symptoms ranged between 74 and 97 hours for 
each week starting 14 January to 29 April 2021 (paragraphs 3.13 to 3.20).

Test and trace in England – progress update  Summary  11 
16	
The overall effectiveness of the test and trace process relies on public 
compliance, which is still low or variable. NHST&T is responsible for addressing 
low levels of public compliance. Academic and scientific experts have noted the 
importance of public compliance with the requirements of test and trace systems 
for them to be effective, and the need to consider behavioural issues and how 
these can be addressed, for example through public health messaging. NHST&T 
has less direct influence over the very start of the process, before someone 
books a test. A key performance indicator for NHST&T is the proportion of new 
infections it identifies through testing, but it has not been able to measure this since 
November 2020. The available survey-based evidence suggests that only a minority 
of people who develop symptoms request a test. It also finds that 43% of all people 
with symptoms, and 82% – 86% of people who test positive say they fully comply 
with self-isolation requirements. NHST&T has no target relating to compliance with 
self-isolation requirements. It is funding and evaluating several pilot approaches to 
improve compliance with self-isolation (paragraphs 1.33 and 3.18 to 3.23).
17	
NHST&T has worked to produce modelled estimates of the impact of its 
activities, which is an inherently challenging analytical task. It is difficult to establish 
the impact that NHST&T activities by themselves have on reducing transmission, 
as they work in conjunction with a range of other measures intended to reduce 
infections (such as social distancing). Initial model analysis by NHST&T estimated 
that, in October 2020, the combination of testing, tracing and self‑isolation resulted 
in a reduction in the R number of 18%-33%, with most of the reduction accounted 
for by self-isolation upon onset of symptoms by individuals. The Department 
also funded a study to evaluate the impact of the COVID-19 app on reducing 
transmissions, which estimated that, based on two models, between October 
and December 2020, approximately 100,000 to 900,000 cases could have been 
prevented by the app. As with any such analysis, the estimates will depend on 
the structure of the model, any counterfactual used, and assumptions about 
key parameters (for example compliance levels with self-isolation). Our review 
highlighted some uncertainties in these estimates: for example, we noted that 
the initial model estimated the impact of NHST&T’s activities by comparison to a 
scenario with only social distancing and no self-isolation; any departure from this 
assumption would reduce the estimated impact (paragraphs 3.24 to 3.28).

12  Summary  Test and trace in England – progress update
18	
NHST&T has made very limited use of its data to assess whether differences 
exist in access to test and trace services for groups at higher risk of COVID-19 
infection, and whether these might contribute to inequalities in outcomes. 
The Department had previously identified that certain disadvantaged groups 
could have difficulty accessing test and trace services. NHST&T has taken further 
steps to address inequalities in access and outcomes since October 2020, for 
example, expanding the coverage of translation services and running targeted 
campaigns to raise awareness of lateral flow testing amongst higher risk groups. 
NHST&T’s regular internal management reporting includes some limited metrics 
aimed at tracking diversity and inclusion. It has also undertaken limited analysis 
of the number of lateral flow tests registered by men and ethnic minority groups. 
However, NHST&T has not yet made use of the data it collects to understand 
if differences in access to symptomatic testing and tracing services exist for 
vulnerable groups, and if so, how they could be contributing to poorer COVID-19 
outcomes for these groups. Our analysis of local authority data suggested wide 
variations in levels of testing but it is not clear whether this has impacted levels 
of infections (paragraphs 3.29 to 3.32).
Future plans and the transition to the UK Health Security Agency
19	
NHST&T will transition to the new UK Health Security Agency (UKHSA) 
between April and October 2021 and there is a risk that NHST&T’s attention will 
be diverted away from efforts to contain the spread of the virus. UKHSA was 
formally established in April 2021 to protect people from infectious diseases and 
external health threats. It will subsume NHST&T, including the Joint Biosecurity 
Centre, and the health protection functions of PHE when fully operational from 
October 2021. NHST&T staff who transfer to UKHSA will need to plan and 
implement the restructuring alongside their work to contain the spread of the 
virus (paragraphs 4.1 and 4.14 to 4.16).
20	
The level of future COVID-19 infections is highly uncertain, but NHST&T 
has not yet made a whole-system plan for beyond July 2021. NHST&T, and from 
October 2021 UKHSA, needs to plan for a range of scenarios that could involve 
an overall reduction in infection levels, while at the same time managing the risk 
of localised outbreaks or an overall resurgence of COVID-19. It has sought to 
improve its understanding of future testing and tracing requirements by undertaking 
modelling and scenario analysis. However, there is still uncertainty about what 
testing and tracing capacity it needs to maintain, and what role asymptomatic 
testing will play beyond July 2021. UKHSA has started to plan its future operating 
model, although it has not completed this work. Local stakeholders told us that 
there is a lack of clarity about the future role national and local bodies will play and 
how the model will incorporate flexible resourcing to respond to local outbreaks 
(paragraphs 4.3, 4.4, 4.6 to 4.13 and 4.15).

Test and trace in England – progress update  Summary  13 
21	
NHST&T does not yet know how it will secure the promised benefits from the 
laboratory infrastructure it has established. In its November 2020 business case for 
the £10 billion expansion of testing in 2020-21, NHST&T stated that the £150 million 
investment in laboratory infrastructure would provide diagnostic preparedness for 
future infectious disease emergencies, as well as early diagnostics for diseases 
such as cancer. However, NHS England and NHS Improvement told us that it was 
not informed of the business plan commitment to use the Test and Trace laboratories 
for this purpose at the time the commitment was made. It has now started to have 
conversations with NHST&T about potential legacy opportunities. NHST&T considers 
that there are various potential benefits from investment in early diagnostics, 
including the ability to treat patients sooner and job creation in the life sciences 
industry. In its November 2020 business case NHST&T committed to drawing up a 
detailed benefits realisation strategy by the end of December 2020, but it has not 
yet done so (paragraphs 4.17 and 4.18).
Concluding remarks
22	
The primary goal of NHST&T is to help break chains of COVID-19 transmission 
and enable people to return towards a more normal way of life. Since it was 
established in May 2020 there have been two national lockdowns and more than 
four million confirmed cases. In order to break chains of transmission, SAGE 
advises that it is desirable that no more than 48 hours should elapse between 
identification of an index case and their contacts self-isolating, and that 80% of 
these contacts would need to be reached. NHST&T now reaches around 85% 
of all contacts, and has reduced the elapsed time to trace contacts for in-person 
PCR tests. However, in‑person PCR tests make up a declining minority of tests, 
and it is less clear whether the wider system is operating as quickly as it needs to. 
Since November, it has rolled out a national asymptomatic testing programme to 
seek to identify those people who do not know they have COVID-19. Only a small 
minority of the tests it has bought have been registered as used, and NHST&T 
is now undertaking research to understand the reasons for this with a work 
programme underway to bring about improvements. The success of the test and 
trace programme relies on the public coming forward for tests when they have 
symptoms, carrying out asymptomatic tests when they do not, and complying with 
instructions to self‑isolate where necessary. NHST&T is responsible for driving up 
public compliance, but research suggests that only a minority of people who have 
COVID-19 symptoms come forward for testing. It has no target for increasing this, 
the uptake of LFD testing or compliance with self-isolation.

14  Summary  Test and trace in England – progress update
23	
NHST&T was set up at speed with a workforce heavily reliant on consultants. 
It had planned to reduce its dependency on consultants but has not yet done so. 
NHST&T operates in an environment of high uncertainty, where demand for testing 
and tracing can be affected at short notice by new variants, case numbers and policy 
decisions (for example, national lockdowns). It is therefore challenging to forecast 
costs with precision. However, there is a very wide margin between the underspend 
of around 10% that NHST&T discussed with the Committee of Public Accounts in 
January 2021, and the 39% underspend of its 2020-21 budget that it reported 
two months later. It has taken steps to increase the flexibility of its contracts for 
contact tracing and future laboratory use and has generally improved its provision 
of data to and engagement with local authorities. However, local authorities still 
struggle to get timely access to the data they need to deal with localised outbreaks 
of COVID-19, and they are unclear on the planned operating model after July 2021. 
To achieve value for money NHST&T must be able to demonstrate both that the 
interventions it delivers are effective in achieving its objective, and that the mix of 
interventions is the most cost-effective use of public resources.
Recommendations
24	
To continue to improve test and trace performance and give NHST&T and its 
successor bodies the best chance of securing their intended impact:
a	
The Department, through NHST&T, and UKHSA if responsible, should, by 
the end of July 2021, develop and agree with its partners a clear strategy for 
integrated national and local service delivery once England is no longer in 
lockdown. This should set out the operational barriers faced by all partners 
(including access to data, funding, scalability, workforce and public compliance) 
and responsibilities and timetable for addressing them.
b	
The Department and UKHSA should, by the end of December 2021, assess 
what standing capacity and infrastructure needs to be retained from NHST&T 
for future emergency responses, alongside plans for how this could be scaled 
up and down as needed, setting out clearly the roles of national and local 
bodies in providing standing and additional capacity.
c	
As overall speed, reach and levels of public compliance still constrain the 
effectiveness of the test and trace approach, by October 2021, the Department, 
through NHST&T and working with relevant delivery partners, must set out 
plans for improving and monitoring the overall process for these areas, and 
which national and local bodies are responsible. In particular, it should address 
how government can best support and encourage citizens in coming forward 
for tests, and complying with self-isolation requirements. This could encompass 
further process improvement and redesign, public health messaging, financial 
or practical support, or other levers available to national and local bodies.

Test and trace in England – progress update  Summary  15 
d	
The Department, through NHST&T, should fill gaps in its data and make full use 
of this information to identify which groups are not engaging with the system 
at each stage and why. It should, by October 2021, publish its assessment of 
differential engagement with each stage of the process, the reasons for it and 
plans to address it.
e	
The Department, through NHST&T, and UKHSA if responsible, should agree 
with NHS England and NHS Improvement whether and how the laboratory 
capacity built up for COVID-19 tests will be used by the NHS. It should publish 
by March 2022 a plan for this legacy, including details of who will own the 
laboratories or contracts, and how flexibility arrangements will work to allow 
them to be diverted to COVID-19 or other urgent testing.
f	
NHST&T, and in due course UKHSA, should provide regular assurance to its 
board and other stakeholders about how it plans to deliver the £2.9 billion of 
efficiency savings required in 2021-22 and manage the other £3.4 billion of 
financial risk. This should distinguish between savings from reduced volumes 
and efficiency savings.

16  Part One  Test and trace in England – progress update
Part One
Update on the government’s test and trace 
approach in England
1.1	
This part of the report provides:
•	
an overview of the NHS Test and Trace Service (NHST&T);
•	
the main developments in the pandemic and government’s approach since the 
end of October 2020;1 and
•	
the development of NHST&T’s approach including identifying asymptomatic 
cases, identifying and containing new variants, developing its approach to 
contact tracing and improving support for self-isolation.
Overview of the NHS Test and Trace Service
1.2	 Test and trace programmes are a core public health response in epidemics that 
can be used alongside wider measures to reduce infections. The basic principles of 
test and trace are identifying individuals, or groups of individuals, with an infectious 
disease and tracing their contacts to limit further transmission.
1.3	 From 28 May 2020, NHST&T, part of the Department of Health & Social 
Care (the Department), has led the government’s test, trace, contain and enable 
approach. Its overall purpose is to “help break chains of COVID-19 transmission and 
enable people to return to a more normal way of life”. NHST&T works in conjunction 
with several public and private bodies, in particular:
•	
Public Health England (PHE) carries out some laboratory testing and contact 
tracing for higher-risk cases in liaison with local authorities;
•	
local authorities run local community testing schemes, can set up contact 
tracing in partnership with NHST&T, and support people self-isolating; and
•	
a range of commercial and academic providers hold contracts to provide 
specific functions and services.
1	
This report should be read in conjunction with our December 2020 report The government’s approach to test and 
trace in England – interim report, which covers the set-up of NHST&T in more detail, and approaches to test and 
trace prior to this.

Test and trace in England – progress update  Part One  17 
1.4	 In addition to testing and tracing activities, NHST&T provides data analysis 
and insight through the Joint Biosecurity Centre (JBC), which was established 
on 1 June 2020. The role of the JBC is to combine epidemiological expertise and 
analytical capability to provide evidence-based, objective analysis and insight on 
the status of the COVID-19 epidemic in the UK and the drivers and risk factors of 
transmission. The JBC, led by a director-general, comprises four boards;
a	
the ministerial board contributes to oversight, ensuring the JBC is delivering 
its objectives effectively for all four nations;
b	
the steering board sets the strategic direction, monitors performance and 
holds the JBC’s director-general to account;
c	
the technical board ensures JBC products have clinical and scientific 
rigour; and
d	
the data science advisory board ensures the JBC can work to the highest 
standards of reliability and reproducibility, and to inform the JBC’s prioritisation 
for integration of new data science models and techniques.
1.5	 The JBC’s objective is to work with partners to provide targeted, timely and 
actionable information to aid local and national decision-making in response to 
COVID-19 outbreaks. It carries out work to inform action on testing, contact tracing 
and local outbreak management. For example, it analyses epidemiological data to 
produce a weekly watchlist of coronavirus cases by local authority, which supports 
the understanding of how infection rates are changing in local areas. It also 
supports the assessment of risks from inbound international travel and advises 
on the COVID-19 alert level. For example, it has developed a risk assessment 
methodology which informs ministerial decisions on red, amber and green list 
countries and territories.
1.6	 Figure 1 overleaf provides an overview of the current process of testing, 
tracing and self-isolating.

18  Part One  Test and trace in England – progress update
Person with 
COVID-19 
symptoms 
Guidance 
that people 
experiencing 
symptoms 
must begin 
10 days of 
self-isolation
Test sent to 
NHS or Public 
Health England 
(PHE) lab for 
processing
Tier 2: 
NHST&T
4 
trace all 
other cases 
to get details 
of contacts*
Tier 3: 
NHST&T 
trace 
contacts to 
advise to 
self-isolate*
Cases and 
contacts 
self-isolate
Refer 
into 
tracing 
scheme 
if the 
result is 
positive
If PCR test 
is positive, 
guidance 
that people 
must 
self-isolate
Test processed in 
commercial lab
Person 
without 
COVID-19 
symptoms
Notes
1 
This is a summary overview of the test and trace process and does not show all possible routes through the stages. 
2 
Government’s testing strategy is organised under several ‘pillars’. Pillar 1 comprises PCR tests (polymerase chain reaction tests, which require processing in a laboratory) processed by 
NHS and PHE laboratories, primarily for NHS staff and patients with a medical need. Pillar 2 comprises tests processed by lighthouse and other public, private and academic laboratories 
primarily for the wider population, including care homes.
3 
LFD tests refer to lateral fl ow device tests, which give results within 30 minutes, introduced from October 2020.
4 
NHST&T refers to National Health Service Test and Trace.
5 
Published guidance sets out when a person must self-isolate, such as if experiencing COVID-19 symptoms, if they test positive for COVID-19, if somebody in a childcare/support bubble 
tests positive and the individual has been in close contact with them since or 48 hours before the test, if the individual is told by NHS T&T or the NHS COVID-19 app they have been in 
close contact with someone testing positive, or if the individual has arrived from abroad.
Source: National Audit Offi ce review of the NHS Test and Trace Service documents and website
Stage in progress
Test and Trace
 
process flow
Guidance/instructions
 
to self-isolate
Figure 1
Overview of the test, trace and isolate process, as at April 2021
There are several different possible user journeys through the process
Symptoms
Access test
Process results
Self-isolate
Transfer into tracing
January to March 
2021 only, when 
the requirement 
for a confirmatory 
PCR test 
was suspended
*Cases and 
contacts may be 
called by telephone 
tracers, or provide 
information 
remotely, for 
example online
LFD
3 rapid result test, 
at home, through local 
authority or workplace, 
care or education setting
In areas with a 
local scheme, 
local authority 
teams trace 
cases that 
NHST&T is 
unable to reach
Tier 1: Local PHE health protection 
teams trace cases (and contacts) 
linked to potential outbreaks and 
advise them to self-isolate
PCR test in 
hospital (Pillar 1)
PCR test in care 
setting (Pillar 2)
PCR test at public site 
or at home (Pillar 2)
Confirmatory PCR test 
(part of Pillar 2)
If LFD result is 
positive, guidance 
that people testing 
positive must begin 
to self-isolate

Test and trace in England – progress update  Part One  19 
The COVID-19 pandemic in the UK since November 2020
1.7	
Our last report covered the period up to the end of October 2020. Since then, 
there has been a very substantial increase and subsequent reduction in COVID-19 
infections and resulting deaths, as shown in Figure 2 overleaf. Office for National 
Statistics estimates of the percentage of people testing positive for COVID-19 
between the last week in November and last week of December more than doubled, 
while deaths related to COVID-19 peaked during January 2021. The number of 
people testing positive through NHST&T almost quadrupled between the last week 
in November (around 98,000) and last week in December 2020, when it peaked 
at around 390,000. Overall test and trace activity increased sharply in December. 
The number of people tested by NHST&T increased by 56% between the end 
of November and the end of December, and the number of cases and contacts 
reached more than quadrupled over the same period. Between 28 May 2020 and 
5 May 2021, 4.1 million people in England tested positive for COVID-19.
1.8	 On 23 November 2020, the government announced its COVID-19 Winter Plan. 
Its objectives were to:
•	
bring the R number (the average number of people infected by someone with 
the virus) below one and keep it there on a sustained basis;
•	
find new and more effective ways of managing the virus and enabling life to 
return closer to normal: including vaccination, improved medical treatments and 
the roll-out of rapid testing to identify and isolate cases quickly; and
•	
minimise damage to the economy and society, jobs and livelihoods by ensuring 
the right support is available for jobs and education settings are safe for 
students to learn.
1.9	 The main developments over winter 2020 are set out in Figure 3 on page 21.
Developments in NHST&T’s approach since November 2020
1.10	 The main developments in NHST&T’s approach over this period relate to:
•	
significantly increasing testing capacity (paragraph 1.11 and covered in more 
detail in paragraphs 2.8 to 2.14, Figure 12 and 3.5 to 3.11);
•	
extending its work to identify asymptomatic cases (paragraphs 1.12 to 1.17);
•	
identifying and containing new variants of COVID-19 (paragraphs 1.19 to 1.25);
•	
developing partnership working with local authorities (paragraphs 1.26 to 1.29);
•	
developing the use of the NHS COVID-19 app (paragraphs 1.30 to 1.32); and
•	
piloting new approaches to support self-isolation (paragraphs 1.33 and 1.34).

20  Part One  Test and trace in England – progress update
Figure 2
Indicators of COVID-19 infections and deaths, and test and trace activity 
in England, November 2020 to April 2021
During December 2020, test and trace activity increased sharply at the same time as the substantial 
rises in levels of COVID-19 infection
Weekly estimate as at end:
Indicator
November 
2020
December 
2020
January 
2021
February 
2021
March 
2021
April 
2021
Estimated percentage 
of people testing 
positive for COVID-19 
(%)
0.88
2.06
1.28
0.37
0.30
0.08
Deaths where 
COVID-19 recorded on 
certificate 
2,728
4,464
5,872
1,531
348
102
NHS Test and Trace Service activity:
–  Positive cases 
identified through 
testing (000s)
98
390
149
45
29
13
–  Number of people 
tested (000s)
1,658
2,593
3,071
3,143
4,868
4,608
–  Cases reached and 
asked for contacts 
(000s)
80
342
131
40
23
9
–  Contacts of cases 
reached and advised 
to self-isolate (000s)
169
683
248
90
75
33
Notes
1 
All data apply to England only. 
2 
Data on positive cases identifi ed through testing, number of people tested, and number of cases and contacts 
reached come from weekly published statistics for the NHS Test and Trace Service (England), for weeks 
commencing 26 November 2020, 31 December 2020, 28 January 2021, 25 February 2021, 25 March 2021 and 
29 April 2021. Figures on the number of people tested may differ from other analyses in the report, which examine 
the number of tests. This analysis is based on the weekly data published on 13 May 2021; fi gures may be revised in 
future releases.
3 
Offi ce for National Statistics (ONS) data on estimated percentage of people testing positive for COVID-19 come 
from the Coronavirus (COVID-19) Infection Survey, for weeks commencing 29 November 2020, 27 December 2020, 
31 January 2021, 28 February 2021, 28 March 2021 and 26 April 2021. 
4 
ONS data on deaths with COVID-19 recorded on the death certifi cate come from weekly provisional counts 
of registered deaths, for weeks ending 4 December 2020, 1 January 2021, 5 February 2021, 5 March 2021, 
2 April 2021 and 30 April 2021. These are rounded to the nearest thousand and calculated by summing the deaths 
where usual region of residence is England.
Source: National Audit Offi ce analysis of Department of Health & Social Care and Offi ce for National Statistics data

Test and trace in England – progress update  Part One  21 
Figure 3
 shows Key developments in test and trace and wider COVID-19 co
ntext, November 2020 to April 2021

22  Part One  Test and trace in England – progress update
Significantly increasing testing capacity
Providing testing facilities for hauliers
1.11	 We cover the increase in overall levels of testing and tracing capacity in 
more detail in Parts Two and Three of this report. In addition to this overall level 
of increase, over Christmas 2020 government had to set up at speed COVID-19 
testing capacity for hauliers, following an announcement by the French Government 
on 20 December suspending all travel from the UK for 48 hours, and subsequent 
to that requiring a recent COVID-19 test as a condition of entry. NHST&T worked 
with the Department for Transport and other departments across government to 
provide testing facilities as well as sanitary and other facilities to hauliers caught in 
the backlog. We spoke to the Road Haulage Association, who told us it was very 
satisfied with how government engaged with the industry and did not see how 
anyone could have done a better job. Government was responsive to feedback, 
for example, providing testing sites further inland to ease congestion at the border.
Identifying asymptomatic cases
1.12	 NHST&T has relied mainly on two types of tests to identify COVID-19, 
polymerase chain reaction (PCR) tests and lateral flow device (LFD) tests. 
PCR tests are more reliable but also more expensive and take longer to provide 
results. LFD tests can be conducted by people at home, work or school with results 
available within 30 minutes. LFD tests are highly sensitive when the viral load is 
high, however, they are less likely to detect COVID-19 when the viral load is low, 
for example, at the beginning or end of an infection (Figure 4).
Roll-out of LFD tests
1.13	 Since October 2020, NHST&T has introduced LFD tests to detect infections 
in people without symptoms. Asymptomatic testing was initially targeted at more 
vulnerable groups (for example, care home residents) or where infection levels 
were likely to be higher, and has since been introduced in various settings (Figure 5 
on pages 24 and 25). In December 2020, government introduced the Community 
Testing Programme, which distributed LFDs to local authorities for large-scale, 
locally-led asymptomatic testing. It was initially only offered to authorities in England 
in Tiers 3 and 4, but eligibility was extended to all local authorities across England in 
January. The scheme is set to run until at least the end of June 2021.
1.14	 As of 9 April 2021, all households in England are eligible for free twice‑weekly 
LFD tests. By 26 May, 691 million test kits had been sent out, with 96 million 
(14% distributed) tests reported, of which 223,000 are positive (Figure 5). 
NHST&T has now started research to understand why the registration of test 
results is so low. Informed by the findings, a programme of work is underway to 
bring about improvement including by raising public awareness, streamlining 
the user journey and tracking distributed devices. As at 26 May 2021, schools, 
colleges and nurseries had registered the greatest number of tests used. 

Test and trace in England – progress update  Part One  23 
Figure 4 shows 
Types of COVID-19 tests

24  Part One  Test and trace in England – progress update
Figure 5
 shows Roll-out of asymptomatic testing using lateral flow device (LFD) tests across 
various sectors in England up to and including 26 May 2021

Test and trace in England – progress update  Part One  25 
1.15	 Several stakeholders have voiced their concerns over the wider use of LFD 
tests in the community and their perceived high risk of false negatives, which could 
provide false assurance to those testing negative. As noted in Figure 4, LFD tests 
are more sensitive when viral load is high and people are most likely to be infectious, 
and relatively less sensitive when viral load is low. The Medicines and Healthcare 
Regulatory Agency has approved the use of LFD tests to identify asymptomatic 
cases and NHST&T considers LFD tests useful for identifying additional COVID-19 
cases from asymptomatic individuals that would not otherwise have been tested 
and identified. NHST&T is clear that LFDs are not a replacement for PCR tests, 
and individuals with symptoms should continue to get a PCR test.
Figure 5 shows Rol
l-out of asymptomatic testing using lateral fl ow device (LFD) tests across 
various sectors in England up to and including 26 May 2021

26  Part One  Test and trace in England – progress update
Challenges with mass testing
1.16	 Sector representative bodies we spoke to voiced common challenges they 
faced around mass testing.2 These included:
•	
local bodies did not always receive relevant or timely data. For instance, 
home care employers told us they did not receive information on what 
proportion of their staff had taken tests and reported the results to NHST&T, 
and tracing data reported by universities went to the national contact tracing 
system before being shared with local public health staff. Local authority 
representatives said that they are not always told in advance about testing 
taking place in their area (for example at workplaces) which made it difficult to 
ensure there were resources in place to support the cases that were identified. 
They also noted that each time a new approach to testing was introduced 
(for example in schools or for international travellers) they had to make the 
case to be given access to the data, rather than being included in the planning.
•	
tracing often fell to staff of local bodies, and the additional time and effort 
required put a strain on resources; which may not be sustainable in the long 
term; and
•	
risk of low uptake of testing. This may relate to poor communications and 
concerns around the efficacy of tests. A positive result requires self-isolation 
with limited financial support, which may be a disincentive, particularly for 
those on lower incomes.
Wastewater testing
1.17	 Testing wastewater allows NHST&T to identify areas with COVID-19 cases 
(including new variants) without relying on individuals to take and record the 
results of tests. Wastewater monitoring is therefore useful for monitoring total 
COVID-19 levels, including asymptomatic cases and symptomatic cases where 
individuals have not taken a test. Testing takes place at sewage treatment works, 
network sites within cities (for example, manholes) and at a number of near‑source 
sites including prisons, managed quarantine facilities and food preparation 
sites. A national monitoring programme is now in place that samples and tests 
wastewater from every region, covering approximately 70% of the population of 
England. Where COVID-19 is identified, this can be followed up with more targeted 
local testing. The wastewater monitoring work is led by the JBC and delivered 
as part of its £1.1 billion budget in 2021-22.
2	
These include representatives of the following sectors: education, health and social care, employers, public health 
and local government.

Test and trace in England – progress update  Part One  27 
Identifying and containing new variants
1.18	 On 14 December, NHST&T announced the sequencing of a new variant of 
COVID-19, which was first identified in Kent in September and appeared to spread 
more rapidly than previous strains. Variant forms of COVID-19 may pose different 
levels of risk in terms of the transmission or severity of illness. As the impact of such 
variants became clear, NHST&T and partners across government started work on 
a strategy to identify and contain them. This strategy has three elements:
•	
Minimising importation through travel restrictions.
•	
Detecting variants in the UK and containing them.
•	
Considerations about when and how to procure new vaccines. 
NHST&T contributes intelligence on the level and type of variants but is 
not otherwise involved in this work.
Minimising importation
Quarantine and testing for international travellers
1.19	 Government imposed restrictions on international travellers entering the 
UK from 15 February 2021. NHST&T supports this work by processing test kits 
and providing telephone support to travellers from lower-risk countries, who are 
required to quarantine at home. All travellers must carry out two PCR tests. If these 
tests are positive, their quarantine is extended, and the results are screened for 
variant forms of COVID-19. NHST&T also traces the contacts of international 
arrivals who test positive, which it told us can involve large numbers per case. 
The JBC has risk‑assessed more than 250 countries and territories, to inform 
ministerial decisions on red, amber and green list countries and the associated 
border measures.

28  Part One  Test and trace in England – progress update
Screening for variants
1.20	NHST&T has two methods to screen for new variants of COVID-19: genomic 
sequencing and the use of a reflex assay. Genomic sequencing sequences the 
genetic material in the virus. This information can be used to identify and track 
the spread of variants and to understand the properties of the different variants 
(for example, whether vaccines are likely to be effective against them and whether 
they are likely to be more or less transmissible than other variants). In May 2021 
genomic sequencing took on average 6.4 days from the point at which the test was 
taken to providing the result. Laboratories also use an ‘early variant calling’ algorithm 
to flag where a test contains any known variant. Early variant calling provides an 
indicative result and automatically alerts the tracing team within six days for 90% 
of viable tests. NHST&T prioritises tests from the NHS and international travellers: 
it aims to provide results for samples from the NHS within four days (and in the 
near‑term within two days), and international travellers’ tests should have an early 
variant call within 96 hours and full sequencing within 144 hours. The reflex assay 
screens test samples against a shortlist of identified variants and can provide 
results within 48 hours. Both methods are now used to screen all viable positive 
test samples. Not all samples are viable: they may not contain enough material 
for screening to be carried out.
1.21	 Genomic sequencing in the UK is coordinated by the COVID-19 Genomics 
Consortium. This brings together government bodies, laboratories and UK public 
health bodies, participating universities and others. NHST&T collects the samples 
through its testing programme and the NHS collects samples from those people in 
hospital. These are then processed and analysed by NHST&T-contracted laboratory 
providers, including the Wellcome Sanger Institute, and the public health agencies 
of the four nations. This overall genomic sequencing has made a significant 
contribution to international efforts to track new variants of COVID-19. As at 22 June 
around 30% of the logs for new variants shared among the international community 
have been provided by the UK, making it the largest single contributor.
Detecting and containing variants in the UK
1.22	From 1 February 2021, the government started carrying out surge testing, 
working with local authorities in areas where COVID-19 variants had been detected. 
Surge testing is carried out using PCR tests, with positive tests sent for genomic 
sequencing. The aim is to monitor and suppress the spread of new variants. As of 
21 April 2021, surge testing had been undertaken in 32 local authorities and was 
currently ongoing in seven.

Test and trace in England – progress update  Part One  29 
1.23	 The approach to surge testing has evolved since February. Initially, it was focused 
on door-to-door testing within affected postcodes. NHST&T now seeks to make 
more use of intelligence-led testing and local authorities’ knowledge. Local authority 
sector representatives told us that in general data for testing and contact tracing 
had improved. However, some challenges remained, for example, getting access to 
information about which individuals have contracted variant strains of COVID-19, and 
receiving routine testing data (including on uptake of testing in different communities 
or settings) which would allow them to identify hotspots more quickly.
1.24	By April 2021, 219,735 cases of variants had been identified, of which 
99.7% related to variants first identified in the UK (with 99% of these being the 
‘Kent variant’). In addition, by that date, there had been 670 cases of the variant 
first identified in South Africa, 132 cases of the variant first identified in India, and 
119 cases of the variant first identified in Brazil.
Developing partnership working with local authorities
1.25	In November 2020, NHST&T concluded that its approach would benefit from 
being less centralised. Its December 2020 business plan outlined a key objective to 
strengthen its partnerships with local authorities and allow more local direction and 
control over testing and tracing. We set out above how local authorities’ role has 
expanded in relation to testing (paragraphs 1.13, 1.14 and 1.22 to 1.24).
1.26	Since the end of October, the number of local authority-run tracing schemes 
has increased. As of March 2021, 149 of 151 upper tier local authorities had a local 
scheme compared with 60 in October. Initially, only complex cases that the national 
service could not reach were passed over to local authorities, but more routine cases 
are now also passed to them. NHST&T provides training, resources and funding to 
support local authorities. Since March 2021, it has also been piloting the Local Zero 
scheme whereby local authorities undertake all contact tracing in their area.

30  Part One  Test and trace in England – progress update
1.27	In the interim report, we noted that NHST&T intended to replace the existing 
contact tracing software system (CTAS) in January 2021. As of May 2021, it had 
begun to roll out the new Integrated Trace System (ITS). On 30 April 2021, a local 
authority flagged concerns about low numbers of cases being passed to it for 
contact tracing. Further investigation by NHST&T uncovered a system error which 
meant that 789 cases across eight local authorities had been mistakenly transferred 
to ITS, rather than CTAS for contact tracing. This led to a delay in tracing contacts 
for about half the cases who were still within the 10-day isolation period. For the 
other half, beyond the 10-day isolation period, contacts were not traced, unless the 
case tested positive for a variant of concern. As per standard procedures, these 
cases were passed to the local PHE team for follow-up and tracing. NHST&T told 
us it had resolved the error and was now making a number of improvements to the 
process, including proactively monitoring the flow of cases into the contact tracing 
system, which it planned to implement by 21 June.
1.28	Local government representatives we spoke to said that general engagement 
and data-sharing had improved between NHST&T and local authorities, but that 
challenges remained. They highlighted difficulties with securing access to data for 
mass testing (paragraph 1.16) and testing uptake for surge testing (paragraph 1.24). 
NHST&T continues to work to improve access to data for local authorities and now 
provides data on positive test results including detailed demographic and other 
information for positive cases. It has recognised the need to continue to develop its 
approach to share data faster, more widely and more easily, with local authorities 
and others. Local government representatives also raised concerns with us about 
a lack of clarity and understanding about local roles and responsibilities, delays in 
the national service passing over responsibilities to local authorities, and multiple 
un‑coordinated pilots and funding streams for local authority activity.
The NHS Test and Trace app
1.29	NHST&T launched its NHS COVID-19 app in September 2020, which 
includes contact tracing features. This followed earlier efforts by NHSX to build the 
app in‑house, which had been abandoned on 18 June. In 2020-21, £76 million was 
spent on the app, including spend by NHSX. There are two ways the app can alert 
people that they have been near someone tested positive for COVID-19:
•	
Contact tracing: The app uses Bluetooth to know when it has come into close 
contact with another device that is running the app. If the users of those nearby 
devices later test positive for coronavirus and report it on the app, the app 
receives an alert with advice on what to do (for example, self-isolate or get a 
test). It does not identify individuals and no data are passed to the national 
or local contact tracing systems.

Test and trace in England – progress update  Part One  31 
•	
Venue check-in: When an app user checks into venues using the app and 
official NHS QR code posters, these data are held on their phone. If people 
who were there on the same day later test positive for coronavirus, the app 
user may get an alert. The venue check-in feature works independently of 
the contact tracing feature.
1.30	By 28 April 2021 in England and Wales the app had been downloaded 
23.3 million times, and it had sent 1.8 million contact tracing alerts in England. 
In the week beginning 22 April, 16.0 million people had the app fully or partially 
enabled on their phone (which is one of several methods used to estimate how 
many people are regularly using the app). NHST&T funded an external assessment 
on the app’s effectiveness which estimated, based on a number of assumptions, that 
it may have prevented 100,000 to 900,000 cases from October to December 2020.3 
There were 1.89 million COVID-19 cases confirmed by a test over that period. 
More detail of this assessment is at paragraph 3.27.
1.31	 By the same date, venues in England and Wales had created 876,037 
QR code posters to allow people to check in to venues using the app. It had been 
used to check in 119.6 million times in England (including around 14 million since 
the reopening of hospitality businesses from 12 April). Across England and Wales, 
304 venue alerts had been sent out (including 22 since 12 April).
Supporting self-isolation
1.32	The support available to people asked to self-isolate has been increased 
since autumn last year, and work is underway to identify what else could be done. 
From September 2020, individuals who meet a specific set of criteria became 
eligible to claim a £500 payment to support them to self-isolate. In addition, 
NHST&T provides a discretionary amount that local authorities can distribute to 
those outside of the prescribed criteria. This was set at £15 million per month for 
all local authorities, which increased to £20 million per month from February 2021. 
The scheme, which had been due to close on 31 January, has been extended 
“into the summer”. In March 2021, the scope of the scheme was extended to 
include parents and guardians of children asked to self-isolate.
1.33	In March 2021, NHST&T launched a medicine delivery service to support 
people self-isolating and allocated £3.2 million per month to deliver the provision. 
NHST&T also provides funding and evaluation tools for 14 pilots examining other 
ways to increase support to people self-isolating. These pilots are expected to 
complete in summer 2021.
3	
The analysis was carried out by researchers from the University of Oxford and the Alan Turing Institute. Two methods 
were used to estimate the number of cases prevented: one estimated 284,000 and the other 594,000.

32  Part Two  Test and trace in England – progress update 
Part Two
Funding and spending for test and trace
Overview of funding and spending
2.1	
In this section, we report on NHS Test and Trace Service’s (NHST&T’s) funding 
and spending, based on unaudited management data. The National Audit Office is 
currently undertaking the financial audit of the Department of Health & Social Care 
(the Department), which includes NHST&T. The Department expects to publish its 
audited accounts later in 2021. The data in this report may differ from audited data 
included in the Department’s annual accounts for 2020-21. Where this is the case, 
the audited figures should be preferred.
Funding and spending in 2020-21
2.2	 Following additional funding in the November 2020 Spending Review, the 
government allocated a total of £22 billion for NHST&T in 2020-21. By the end of 
March 2021, NHST&T had spent £13.5 billion (Figure 6). Of this, £10.4 billion (77%) 
was on testing, including £4.2 billion on mass testing and £3.1 billion on laboratories 
and associated costs. NHST&T had also spent £1.8 billion (13%) on ‘contain’ 
activities (to identify local COVID-19 outbreaks and support local responses to 
the pandemic), and £0.9 billion (7%) on tracing activities.
2.3	 In 2020-21, NHST&T underspent its budget by £8.7 billion, or 39%. 
Testing, in particular asymptomatic lateral flow device (LFD) testing, and laboratories 
and associated costs accounted for most of the underspend (£7.9 billion, 91% of 
underspend). NHST&T told us that a high level of forecast demand for tests in 
January and February did not materialise, in part, due to the introduction of the 
national lockdown and other measures from December. In addition, the roll-out of 
LFD tests for asymptomatic testing initially planned in January did not start until 
March due to national lockdown and eventual uptake was much lower than expected. 
NHST&T told us that £2.2 billion savings from its improved contract management 
and procurement have also contributed to the underspend. This include around 
£1 billion through price or rate reductions and some £1 billion through cancelled 
project or reductions in committed volumes.

Test and trace in England – progress update  Part Two  33 
Figure 6 shows T
The NHS Test and Trace Service 2020-21 budget and spend, by main 
programme area

34  Part Two  Test and trace in England – progress update 
2.4	 Out of its total spend, NHST&T paid out grants totalling £2.2 billion to local 
authorities for various activities. Most of this grant funding, £1.7 billion, was for 
‘contain’ activities: this accounted for nearly all of NHST&T’s £1.8 billion spend 
on such activities. NHST&T also provided £176 million for test and trace support 
payments, and £13 million for practical support for self-isolation. It paid £149 
million for rapid testing in adult social care, £121 million for community testing, 
and £3 million to 27 local areas for surge testing.
2.5	 In November 2020, NHST&T set out a business case for increasing its budget 
by £10 billion to £22 billion for 2020-21, as allocated in the 2020 Spending 
Review. The additional funding was intended to support the establishment of 
mass population testing (primarily through LFD tests), with an expansion in the 
number of tests to 2.5 million to 4.5 million tests a day from December 2020. 
The majority of this funding, £4.2 billion, was for testing supplies such as test kits, 
followed by laboratory processing (£1.1 billion), logistics (£729 million), and digital, 
call centre and marketing (£689 million).4 The business case described mass 
testing as the next stage of NHST&T’s development, furthering its aim to reduce 
transmission of the virus, thereby resulting in fewer infections, hospitalisations 
and deaths, and allowing society and the economy to reopen and remain open. 
It noted that “mass testing, driven by new technologies, may be faster than 
creating a vaccine or an anti‑viral drug, and may help to avoid lengthy and costly 
lockdowns”. A third national lockdown in England started on 4 January 2021, 
with restrictions eased in stages from 8 March 2021.
Budget and plans for 2021-22
2.6	 The November 2020 Spending Review allocated £15 billion to NHST&T 
for 2021-22. As of May 2021, NHST&T was working to a planned budget of 
£14.2 billion, which is reliant on achieving efficiency savings of £2.9 billion. It told 
us that HM Treasury had made an accounting adjustment of £807 million to its 
Spending Review allocation of £15 billion.5 NHST&T was planning to request that 
this is added back to bring its budget up to the originally notified £15 billion.6 
It anticipated spending £13.1 billion, 73% of the budget, on testing, including 
£4.7 billion on mass rapid-result testing, £3.8 billion on laboratory costs and £3.6 
billion on laboratory‑processed tests (Figure 7). However, there remain many 
uncertainties about the future course of the virus and the consequences for test 
and trace services and spend. NHST&T also flagged the risk of additional spending 
of around £3.4 billion. This reflected the possibility of higher transport and storage 
costs if more LFD tests than forecast are needed, particularly if these are imported 
from outside the UK, as well as contract costs related to mass testing.
4	
The business case also included an adjustment for optimism bias of £2.3 billion.
5	
NHST&T told us that under HM Treasury guidelines, the stock purchases are accounted for as capital spend with 
consumption reflected as revenue spend. NHST&T estimated a 2021-22 year-end stock value of £140 million, 
£1,260 million lower than the opening stock value of £1,400 million. This creates an overall negative capital 
budget value of £807 million in 2021-22, net of other capital spend of £454 million. This was offset against 
the published £15 billion budget.
6	
Assuming no major policy changes, HMT expects expenditure to remain within the allocation provided to NHST&T 
in 2021-22.

Test and trace in England – progress update  Part Two  35 
Figure 7
 shows Estimated budget for the NHS Test and Trace Service for 20
21-22, by main programme areas, as at M
ay 2021 

36  Part Two  Test and trace in England – progress update 
Contract spend and management
2.7	 By the end of March 2021, the Department had signed 964 contracts with 
454 suppliers across the private and public sector for activity related to NHST&T 
(Figure 8). The total value of the contracts was £14.1 billion. Testing accounted for 
£12.7 billion, or 90% of the total contract value. Tracing accounted for £1 billion, 
7% of the total contract value. Ten of the largest suppliers account for more than 
half (£7.3 billion, 52%) of the total contracts value (Figure 9).
Figure 8 shows N
Number and value of contracts signed by the NHS Test and Trace Service 
by programme areas, as of the end of March 2021
Post publication this page was found to contain an error which has been corrected (Please find Published Correction Slip)

Test and trace in England – progress update  Part Two  37 
2.8	 Of the £14.1 billion total contract value, £7.5 billion (or 53% of the total contract 
value) was awarded directly under emergency regulations without competition, 
while £3.4 billion was awarded under existing frameworks and £3.1 billion through 
other routes (Figure 10 overleaf). NHST&T let, extended or varied fewer contracts 
using emergency regulations in the period January to March 2021 (28 contracts or 
6% of contracts), than in April to June 2020 (51 contracts, or 46% of contracts) 
(Figure 10). Over the same timeframe, the value of contracts let, extended or varied 
under emergency regulations decreased as a proportion of all contracts (from 
76% down to 52%), but the absolute value more than doubled (from £1.1 billion 
to £2.6 billion). The increase in the absolute value was mainly due to a £1.9 billion 
contract for LFD test kits with Innova Medical Group Inc awarded in the period 
January to March 2021.
Figure 9 shows 
The 10 suppliers with the total highest contract values signed by 
the end of March 2021 

38  Part Two  Test and trace in England – progress update 
Figure 10
Value and number of new contracts, contract extensions and variations, by award route and date of 
contract signature up to March 2021
The NHS Test and Trace Service has reduced the number of contracts it awarded under emergency regulations since
April to June 2020, but the reduction in the value of these contracts is much smaller
Value of new contracts, contract extensions, and variations (£m)
2019-20
2020-21
Before 
April 2020 
April to
June 2020
July to 
September 2020
October to 
December 2020
January to 
March 2021
Total value 
of contracts
Call off from framework
6 
244 
747 
1,104 
1,337 
3,445
Direct award under 
emergency regulation 
216 
1,051 
1,905 
1,768 
2,565 
7,504 
Other 
 0 
 81 
680 
1,349 
992 
3,102 
Total
222
1,376
3,332
4,221
4,893
14,051
Proportion under 
emergency regulation
97%
76%
57%
42%
52%
53%
Number of new contracts, contract extensions and variations
2019-20
2020-21
Before 
April 2020 
April to
June 2020
July to 
September 2020
October to 
December 2020
January to 
March 2021
Total value 
of contracts
Call off from framework
9
36
94
235
327
703
Direct award under 
emergency regulations 
8
51
45
58
28
190
Other 
2
24
32
116
148
322
Total
19
111
171
409
503
1,215
Proportion under 
emergency regulation
42%
46%
26%
14%
6%
16%
Notes
1 
The NHS Test and Trace Service can award its contracts through several different routes, including through framework agreements in place with 
the Government with or without bidding, direct awards to fi rms and partners under the power of emergency Regulation 32, or variations to existing 
contracts under Regulation 72. It also contracts with other Government or public bodies under arrangements such as memoranda of understanding 
and grants.  
2 
The award route can differ for the initial contract and any subsequent extensions or variations. Because of this, the table breaks down value and 
number of contracts separately for initial contracts, contract extensions and variations. The number of contracts total to more than the number 
of initial contracts, as shown in Figure 8.
3 
Other includes grants, memoranda of understanding with other public bodies such as Offi ce for National Statistics and universities, single-source 
contracts, public to public collaboration under Regulation 12 and contracts awarded under Regulation 14 as well as variations under regulation 72. 
It also includes directly awarded contracts with small (subthreshold) values awarded directly without competition.
4 
Two contracts let off framework without commencing and signatory dates with a total value of (£6 million) are not included in the table.
5 
Two contracts with an associated value of £6 million could not be allocated to a fi nancial quarter, but are included in the overall totals. 
The quarterly fi gures in the ‘call off from framework’ and ‘total’ rows therefore do not sum to the total.
Source: National Audit Offi ce analysis of contracts data provided by the NHS Test and Trace Service

Test and trace in England – progress update  Part Two  39 
2.9	 NHST&T told us that given the emergency nature of the initial response and 
the need to scale up operations at speed, it had to use the private sector to respond 
quickly under power of the emergency regulation. The emergency arrangements 
bring risks to value for money due to a lack of competition and normal regulatory 
processes. However, for some contracts, NHST&T told us that there was only one 
possible supplier. This was the case for the Innova Medical Group Inc contract 
(paragraph 2.8), which was at that time the only supplier of LFDs for self-test 
approved by the Medicines and Healthcare products Regulatory Agency (MHRA). 
NHS T&T has put in place a more structured approach to contract management. 
For all contracts, teams must record a procurement strategy which includes 
justification for the route to market. This is then subject to review and approval by the 
NHST&T Approvals Secretariat, overseen by the Director of Commercial Operations.
Capacity and utilisation
2.10	 In March 2021, the Committee of Public Accounts reported that a combination 
of challenges in matching supply and demand for NHST&T’s test and trace services 
and the inflexibilities in some of its contracts had led to either sub-standard 
performance or poor utilisation of the capacity it had paid to put in place. NHST&T 
needs to manage the balance between having spare capacity to meet unexpected 
surges in demand for services and making efficient use of its resources to deliver 
value for money. Below, we examine available information on capacity and utilisation 
across the test and trace process.
2.11	 NHST&T told us that, between September and November 2020, it put in place 
a team with commercial and contracting expertise drawn from across government 
to strengthen its contract and operational management. Since November, it has built 
more flexibility into its contact centre contracts to allow NHST&T to adjust capacity. 
For example, it increased the amount by which it can adjust capacity from 20% to 
25% and reduced the notice periods.
Laboratories and testing sites
2.12	 NHST&T uses a variety of in-person and other routes to collect polymerase 
chain reaction (PCR) tests, alongside different types of laboratories to process them, 
including Lighthouse laboratories, partner laboratories and surge laboratories.7 At the 
end of April 2021, NHST&T was operating 1,756 testing sites (excluding 500 mobile 
and satellites testing sites) and nine Lighthouse laboratories. NHST&T has also 
commissioned one high-capacity ‘mega-laboratory’, which is not yet operational.
7	
To scale up testing capacity, NHST&T built new “lighthouse laboratories” to process COVID-19 PCR tests, 
in partnership with universities, the NHS and commercial sectors across the country. It also established a new 
large‑scale “mega lab” at Leamington Spa. Partnership laboratories are those laboratories which NHST&T 
does not own but has contracted with to process PCR tests on its behalf.

40  Part Two  Test and trace in England – progress update 
2.13	 In February 2021, NHST&T estimated that the average end-to-end cost for a 
PCR test varied from £17 for samples collected through satellite sites and processed 
at Mega-labs to £52 for samples collected by local test services and processed 
at Lighthouse laboratories8. However, this assumed activity levels at testing sites 
and laboratories is in line with forecast capacity. As actual activity has been much 
lower than forecast capacity, the actual unit costs are likely to be higher than 
these estimates.
Testing sites
2.14	 For in-person tests, NHST&T operates regional and local sites on a fixed basis, 
as well as setting up mobile test units in response to requests from local authorities. 
NHST&T has not set a target level of utilisation for these regional and local test sites, 
and on average, only around one-quarter of their capacity has been used (Figure 11).
Laboratories
2.15	 NHST&T successfully expanded the total theoretical processing capacity for 
PCR tests from 500,000 per day at the end of October to 800,000 by January 2021 
(Figure 12 on page 38).9 For its laboratory capacity, NHST&T sets a threshold 
utilisation rate of 80% of its maximum daily testing capacity, beyond which a 
laboratory does not operate safely or reliably (Figure 12 on page 38).10 NHST&T 
does not have a target utilisation rate for laboratories. In 2020-21 it aimed to 
have sufficient capacity to respond to a peak in infections on any day. Between 
November 2020 and April 2021, the average utilisation rate for laboratories 
was 45%, well below the recommended rate. It has fallen within this period too, 
from 53% between November and January to 38% between February and 
April. Between October 2020 and March 2021, average utilisation was 60% for 
Lighthouse laboratories and 26% for non-Lighthouse laboratories, which include 
partner laboratories. NHST&T is working with laboratory suppliers to update 
contracts and intends to close those that it no longer needs, including exiting all 
partner laboratories.
Contact tracers and call handlers
2.16	 NHST&T outsources a range of contact centre services, primarily for tracing 
cases and contacts, as well as monitoring people who are self-isolating and staffing 
the 119 helpline. The national tracing service provides a central pool of telephone 
staff, alongside text, web and email communications. Its tracers are made up of 
health professionals who make initial contact with people testing positive (Tier 2) 
and call handlers who follow up with their identified contacts (Tier 3).
8	
The unit cost includes cost for test kits, sample collection and courier costs, lab processing including reagents but 
does not include all costs associated with programme overheads and supporting functions, for example workforce, 
digital, call centre and marketing, or fixed or stepped costs (for example establishment of new facilities or fixed 
contractual costs for logistics). Different laboratories use different technologies, which also contributes to the 
differences in unit costs.
9	
NHST&T manages all PCR laboratories on behalf of all UK nations. The total test capacity includes all PCR test 
capacities made available through NHST&T. When calculating the utilisation rate of PCR laboratories, we included 
all PCR tests carried out across the UK through NHST&T.
10	 In our interim report published in December 2020, we noted that NHST&T recommends a utilisation rate of 85% 
of published capacity to ensure a safe and sustainable service.

Test and trace in England – progress update  Part Two  41 
Figure 11 shows Util
isation of COVID-
19 te
st
 sites in England, 1 October 2020 to 31 March 2021

42  Part Two  Test and trace in England – progress update 
Number of daily reported PCR tests
Theoretical laboratory capacity for PCR test processing
 PCR laboratory utilisation rate (%)
The NHS Test and Trace Service recommended utilisation rate (80%)
Notes
1 
PCR tests require processing in a laboratory and were the primary test in use for COVID-19 prior to November 2020. 
2 
PCR testing capacity is the seven-day daily average testing capacity reported by the NHS Test and Trace Service (NHST&T) laboratories for 
the corresponding period. It includes PCR capacities made available by NHST&T across the UK.
3 
PCR laboratory utilisation rate is calculated by dividing the seven-day daily average number of tests carried out by the seven-day daily average 
theoretical capacity of laboratories for PCR tests across the UK. 
4 
NHST&T sets a threshold utilisation rate of 80% of its maximum daily testing capacity, beyond which a laboratory does not operate safely or reliably.  
Source: National Audit Offi ce analysis of the NHS Test and Trace Service weekly statistics and daily dashboards
Figure 12
Trends in COVID-19 polymerase chain reaction (PCR) tests capacity, the number of tests processed, 
and laboratory utilisation in the UK , 28 May 2020 to 5 May 2021
Between November 2020 and April 2021, the average utilisation rate of the theoretical PCR laboratory capacity made available 
was 45%, well below the safe utilisation threshold rate of 80%
0
10
20
30
40
50
60
70
80
90
100
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
28 May
28 Jun
28 Jul
28 Aug
28 Sep
28 Oct
28 Nov
Week ending
28 Dec
28 Jan
28 Feb
31 Mar
2021
2021
7 day average of testing capacity and tests reported
Utilisation rate (%)

Test and trace in England – progress update  Part Two  43 
2.17	 NHST&T aims for its contact centre staff to work to an average utilisation 
rate of 50% (the percentage of paid time spent working). However, daily demand 
for tracing and other services, and resulting utilisation rates, vary substantially, as 
shown in Figure 13 (overleaf). The utilisation rate across different services peaked 
at 49% at the beginning of January 2021, before falling to around 11% by the end 
of February, although it has since improved to between 17% and 37% (25% on 
average) between April and May. The unit cost per contact traced went up from 
around £5 in October to £47 in February when the utilisation rate was at its lowest. 
Overall, however, utilisation rates have remained well below the target rate of 50% 
between November 2020 and May 2021. NHST&T told us it is challenging to match 
available staff to demand due to the very variable demand, and uncertainty in 
forecasts of infection levels. It said the main reason for lower utilisation in this period 
was because the expected high volume of infections did not materialise. It has since 
reduced the number of Tier 3 tracers from 18,000 (full-time equivalents) in October 
to 13,200 by 15 February and 10,700 by 8 March. NHST&T told us that some service 
lines, for example call handlers tracing contacts of international arrivals, frequently 
had a utilisation rate above 70%, but its current system made it difficult to move 
call handlers between services. It also told us that it intends to put new contracts in 
place from September, which will allow contractors to switch call handlers trained 
to work between different services and use staff more efficiently.
Rapid-result LFD tests
2.18	 Since October 2020, NHST&T has started the roll-out of rapid-result 
LFD tests, as part of its plans for regular testing for people without symptoms 
(paragraphs 1.12 to 1.16). By the end of March 2021, the Department had purchased 
around one billion test kits at the cost of around £3 billion. NHST&T has distributed a 
total of 691 million LFD test kits through a range of channels by 26 May.
2.19	 NHST&T assumed that up to 40 million people in England would be eligible 
for LFD tests, with a daily UK consumption of about six million when schools 
reopened on 8 March, rising to more than eight million a day towards the end of 
May. It forecast that between 1 March and 30 May, a total of 655 million LFD tests 
would be carried out across the UK.11 However, the average weekly number of LFD 
tests carried out and reported to NHST&T in England has been below or around 
the forecast daily estimates, with 2.8 million per week between 31 December and 
10 March, seven million before the Easter break, and 5.5 million between mid‑April 
and the end of May, after tests were made available to everyone. The total number 
of LFD tests reported up to 26 May is 96 million, 14% of the 691 million distributed. 
It is not clear exactly how many other test kits have been used, because there is no 
system in place to monitor or ensure that everyone reports their test results once a 
test has been carried out. NHST&T told us that it believes a further 254 million tests 
could have been used but not registered and it is working to improve its dispatch 
and registration system to aid its understanding and close the gap.
11	
Adjusting for the population in England, this is equivalent to a forecast consumption of 550 million lateral flow device 
tests for England between 1 March and 30 May 2021.

44  Part Two  Test and trace in England – progress update 
Figure 13 shows D
aily utilisation rates o
f nat
io
nal contact tracers and other contact centre staff in England, November 2020 to May 2021

Test and trace in England – progress update  Part Two  45 
Consultancy and workforce
2.20	To scale up services rapidly, NHST&T relied heavily on consultancy support at 
its central office. NHST&T told us that this is because many of the skills required 
were not available from the civil service within the timeframe, and some of the 
skills and capacities required are on a short-term basis to support the ‘build’ of the 
organisation. At the time of this report, NHST&T provisionally estimated that it had 
spent £372 million on agency and contractor staff and £195 million on consultancy 
fees, compared with £52 million on permanent and seconded staff in 2020-21. 
It had not yet completed its year-end checks, and anticipated that the amount 
recorded as consultancy spend would increase. Our separate enquiry on contract 
value and spend to the top 10 consultancies, indicated spend of around £300 million 
on these suppliers, with £174 million on the top supplier Deloitte (Figure 14).
Figure 14 shows T
Top 10 consultancies with the highest committed contract values with 
NHS Test and Trace and actual spending to the end of March 2021

46  Part Two  Test and trace in England – progress update 
2.21	Consultants are much more expensive than civil servants or temporary 
staff from other public services. While access to consultancies has provided 
NHST&T with the skills and capacity needed to build up the test and trace 
capacities quickly, it may not, as NHST&T recognised itself, be the best use of 
public money to rely on consultancies to deliver the services on an ongoing basis. 
In November 2020, NHST&T outlined plans to reduce the number of consultants 
it employed. Between November 2020 and February 2021, consultants employed 
by NHST&T accounted for more than half of its staff (51%), reducing to 45% as 
at mid‑April. However, the number of consultants employed in April (2,239) is still 
higher than that in December (2,164) (Figure 15). NHST&T set a target to reduce 
the ratio of consultants to civil servants to 60%, but between December 2020 
and March 2021 this ratio remained at 76%. NHST&T also told us that, between 
January and March, it has increased the number of consultants employed due 
to the expansion of asymptomatic testing, reopening of international borders 
and tracking variants of concerns.
2.22	Its current plans to reduce its use of consultants include:
•	
not extending around a third of the 189 consultancy and contingent labour 
contracts expiring by the end of March 2021;
•	
replacing consultants with staff from Public Sector Resourcing (PSR);
•	
introducing a two-week notice period for all consultants; and
•	
appointing a Senior Responsible Owner for the reduction of the Deloitte 
contract, from 1,035 consultants in February down to 449 in September.
2.23	NHST&T also has an ongoing recruitment campaign to increase the number 
of staff it employs directly. However, NHST&T highlighted many challenges it is 
facing to achieve its plans, such as a shortage in specialist skills, for example, 
data scientists and technical architects, in the civil service, uncertainties associated 
with the transition to the new UK Health Security Agency and comparatively low 
salaries in the civil service. We note that many of these are common challenges 
faced by other government departments.

Test and trace in England – progress update  Part Two  47 
Figure 15 sho
ws NHS Test and Trace S
e
rvice central office s
t
aff head counts, November 2020 to April 2021

48  Part Three  Test and trace in England – progress update
Part Three
Performance and effectiveness of test and trace
3.1	
Part Three examines trends in the performance of test and trace, focusing 
on the period October 2020 to April 2021. It reviews the available measures of 
effectiveness of test and trace in relation to its overall aim of breaking the chains 
of transmission of COVID-19 and considers how access to, and outcomes from, 
services vary for different groups in the population.
Performance commitments and targets
3.2	 In December 2020, the NHS Test and Trace Service (NHST&T) published its 
second business plan, which set out its objectives and priorities for the next four 
months. It detailed several specific commitments to improve performance and 
capacity, including:
a	
Testing: further expansion of testing, including through the scale-up of rapid 
lateral flow device (LFD) tests; improvements to the booking and delivery 
process to ensure access to tests and faster results; and increasing the number 
of test sites, so that most people can get a test within 1.5 miles or 30 minutes 
for walk-up facilities.
b	
Tracing: improvements to the tracing system to streamline and speed up the 
process for users, with targets, by the end of January 2021, to reach 90% of 
people who test positive and 85% of identified contacts; and, by March 2021, 
reach around 80% of contacts within 72 hours of booking an (in-person) test. 
NHST&T also had an objective to expand the role of local contact tracing, 
including helping to set up local tracing partnerships in up to 90% of local 
authorities by December 2020.
c	
Support for self-isolation: a range of actions intended to support and 
encourage self-isolation, including NHST&T making support payments 
available to people notified to self-isolate by the NHS COVID-19 app, using 
follow-up calls to help local authorities identify those needing support during 
self‑isolation, and marketing campaigns and local collaborations to improve 
people’s understanding of the need to self-isolate and available support.

Test and trace in England – progress update  Part Three  49 
3.3	 The Executive Committee of NHST&T regularly reviews a range of key 
performance measures (Figure 16). From December, NHST&T identified six metrics 
as key drivers of reducing transmissions of COVID-19, with specified targets for four 
measures. We cover performance against these and other indicators in the following 
two sections.
Figure 16
Internal performance measures and targets
The NHS Test and Trace Service monitors a range of measures, some of which it identifies as key drivers 
of reducing transmission of COVID-19
Indicator
Target
Comments
(%)
Percentage of new infections identified
60
Identified as key driver of reduction in 
R number, not available from November 
(see paragraphs 3.18 to 3.20) 
Percentage of index cases reached
90
Identified as key driver of reduction 
in R number
Percentage of contacts reached
85
Identified as key driver of reduction 
in R number
Time from test ordering to 
contacts reached (in-person 
tests only, percentage reached in 
72 hours; median time also monitored)
80 
for percentage 
reached
Identified as key driver of reduction 
in R number. In March 2021, the target 
was strengthened to 80% reached 
within 48 hours
R number estimate
Not set
Number of positive cases
Not set
Number of Pillar 2 tests processed
Not set
Pillar 2 laboratory capacity
Not set
Up to the beginning of March 2021
Pillar 2 laboratory utilisation rate
Not set
Number of positive tests
Not set
Number of cases reached
Not set
Identified as key driver of reduction in 
R number
Number of contacts reached
Not set
Identified as key driver of reduction in 
R number
Isolation compliance
Not set
Not monitored on weekly basis from March
Lateral flow device (LFD) test 
kits registered
Not set
New indicator from mid-March
Notes
1 
The R number is the average number of people infected by someone with the virus.
2 
PCR (polymerase chain reaction) testing is organised under several ‘pillars’. Pillar 2, which makes up the majority 
of PCR tests, comprises tests processed by lighthouse and other public, private and academic laboratories 
primarily for the wider population, including care homes.
3 
Contacts refer to those covered by the national service and local authorities, excluding those covered by 
regional Public Health England teams.
4 
Isolation compliance refers to an internal survey run by NHS Test and Trace. 
5 
Measures are for England, except for R estimates and Pillar 2 test measures, which are for the UK. 
Source: National Audit Offi ce analysis of the NHS Test and Trace Service Executive Committee papers

50  Part Three  Test and trace in England – progress update
Trends in NHST&T performance
3.4	 This section examines indicators of activity and performance for NHST&T.12
Number and types of tests carried out
3.5	 In its December Business Plan NHST&T set out an objective to expand testing 
capacity, including rapid-result LFD tests which became available in October. 
About 102 million tests were taken in community settings (under Pillar 2 of the 
testing programme) between the start of November 2020 and the end of April 2021 
(Figure 17), with the weekly number increasing from 1.2 million to a high of 8.7 million 
in early March. Most of these tests, about 69 million, were LFD tests. LFD tests 
accounted for less than 1% of all tests in October but their use has expanded 
significantly, peaking at 88% of all tests (or 7.7 million LFD tests) in the second 
week of March. From November onwards, NHST&T required positive LFD results to 
be confirmed with a positive polymerase chain reaction (PCR) test before contact 
tracing began. Between November and April, around two-thirds of positive LFD 
results were followed up by confirmatory PCR tests. At the start of April, 76% of 
confirmatory PCR tests were positive.
Turnaround times for test results
3.6	 For in-person PCR tests taken in the community, the turnaround time for 
people to receive test results after taking a test has improved.13 At the end of 
October, the proportion of people receiving results within 24 hours stood at 38%, 
increasing to 90% at the end of April. However, this proportion fell to a low of 17% 
during December (Figure 18 on page 48).14 NHST&T told us this dip was mainly 
due to the unexpected increase in demand following the easing of lockdown and 
the emergence of the new Alpha variant, first identified in Kent. It also had to 
manage staff shortages in laboratories arising from COVID-19, a shortage in critical 
supplies affecting one laboratory, and IT failures delaying the uploading of test 
results to some laboratories. It said it attempted to mitigate the impact by increasing 
capacity through new Lighthouse and surge laboratories and expanding activity 
at existing ones. Over the period November 2020 to April 2021, 57% of people 
taking tests in‑person (outside a hospital setting) received results within 24 hours, 
an improvement on the 41% we noted in our interim report for May to October 
2020. Over the same period, 8% of people taking a home test kit received results 
within 24 hours.
12	 In this section, we refer to the period November-April. As performance data are published weekly, this covers the 
week commencing 5 November 2020 up to and including the week commencing 29 April 2021.
13	 These are in-person tests taken in community settings under Pillar 2, which excludes tests in hospital settings 
(Pillar 1). For the period May 2020 to April 2021, in-person PCR tests account for 37% of all Pillar 2 PCR tests.
14	 This analysis does not include LFD tests, which do not need to be sent off to a laboratory for processing.

Test and trace in England – progress update  Part Three  51 
Number of PCR tests taken
Number of LFD tests taken
LFD tests as a proportion of tests taken (%) 
Notes
1 
PCR tests look for the presence of the COVID-19 virus using a swab which is processed in a laboratory. They are predominantly used for symptomatic 
individuals, regular asymptomatic testing in social care, and to confi rm a positive LFD test result. Most results are returned within 24 hours.
2 
LFD tests, sometimes referred to as rapid tests, test for the presence of proteins (antigens) produced by the COVID-19 virus using swabs that give 
results in 30 minutes or less without the need for laboratory processing. They are used mainly for people without symptoms. 
3 
The number of tests includes all tests within the control of the NHS Test and Trace Service (including PCR and LFD tests) and tests sent out and 
subsequently returned for processing. It does not include LFD tests that were not registered through this route.
4 
Pillar 2 comprises tests processed by lighthouse and other public, private and academic laboratories primarily for the wider population, including 
care homes.
Source: National Audit Offi ce analysis of data published by the Department of Health & Social Care
Figure 17
Number of Pillar 2 polymerase chain reaction (PCR) tests and lateral fl ow device (LFD) tests taken, 
and the percentage of LFD tests, in England week commencing 28 May 2020 to 29 April 2021
LFD tests now account for the majority of all tests taken
0
10
20
30
40
50
60
70
80
90
100
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
28 May
11 Jun
25 Jun
9 Jul
23 Jul
6 Aug
20 Aug
3 Sep
17 Sep
1 Oct
15 Oct
29 Oct
12 Nov
26 Nov
10 Dec
24 Dec
7 Jan
21 Jan
4 Feb
18 Feb
4 Mar
18 Mar
1 Apr
15 Apr
29 Apr
Number of tests taken 
LFD tests as a proportion of tests taken (%)
Week commencing
2020
2021

52  Part Three  Test and trace in England – progress update
Notes
1 
Pillar 2 comprises tests processed by lighthouse and other public, private and academic laboratories primarily for the wider population, including 
care homes. The metric shown only covers in-person Pillar 2 tests, ie taken at a regional, local or mobile testing site.
2 
Polymerase chain reaction (PCR) tests look for the presence of the COVID-19 virus using a swab which is processed in a laboratory. They are 
predominantly used for symptomatic individuals, regular asymptomatic testing in social care, and to confi rm a positive lateral fl ow device test 
result. Most results are returned within 24 hours.
Source: National Audit Offi ce analysis of data published by the Department of Health & Social Care
Figure 18
Percentage of Pillar 2 COVID-19 test results received within 24 hours in England, week commencing 
28 May 2020 to 29 April 2021
The timeliness of Pillar 2 test results has improved since October 2020, excluding a dip in December 2020
0
10
20
30
40
50
60
70
80
90
100
28 May
4 Jun
11 Jun
18 Jun
25 Jun
2 Jul
9 Jul
16 Jul
23 Jul
30 Jul
6 Aug
13 Aug
20 Aug
27 Aug
3 Sep
10 Sep
17 Sep
24 Sep
1 Oct
8 Oct
15 Oct
22 Oct
29 Oct
5 Nov
12 Nov
19 Nov
26 Nov
3 Dec
10 Dec
17 Dec
24 Dec
31 Dec
7 Jan
14 Jan
21 Jan
28 Jan
4 Feb
11 Feb
18 Feb
25 Feb
4 Mar
11 Mar
18 Mar
25 Mar
1 Apr
8 Apr
15 Apr
22 Apr
29Apr
Test results received within 24 hours of taking a test (%)
Week commencing
2020
2021

Test and trace in England – progress update  Part Three  53 
Tracing cases (people testing positive for COVID-19)
3.7	 NHST&T transferred 3.2 million positive cases to its tracing service between 
November and April (Figure 19 overleaf).15 The numbers transferred each week 
largely reflect trends in positive cases. There was a very sharp increase in weekly 
numbers during December to a high of 388,150 in the last week of that month, 
before numbers steadily decreased to 9,615 by the end of April.16
3.8	 By the end of January, NHST&T aimed to reach 90% of people testing 
positive for COVID-19. The proportion of cases reached by the tracing service each 
week improved from 86% in October to meet the 90% target in mid-March 2021. 
The target was subsequently met for most weeks up to the end of April, apart from 
the first and third weeks of that month when performance dipped slightly.17
3.9	 The time taken by the national service to reach cases improved during 
November to April.18 In the last week of October, 72% of these cases were reached 
within 24 hours, increasing to 81% by the end of April (Figure 20 on page 51).
Tracing contacts (close contacts of those testing positive for COVID-19)
3.10	 Since December 2020, NHST&T has had a target to reach 85% of contacts.19 
During October 2020, the percentage reached was relatively stable at around 60% 
each week (Figure 21 on page 52). It then increased significantly during November, 
rising to 94% by the end of January and remaining above the 85% target until 
mid-April, when it fell to 84%.20 The November increase may, in part, be attributed 
to changes NHST&T made to how household contacts were recorded from the 
middle of that month. Previously these contacts were counted as reached after 
being contacted individually. They were now deemed reached if the original case 
provided basic information about the contact and agreed to tell them to self-isolate.
15	 Cases in the tracing system are managed either by the national tracing service, including harder to reach cases 
passed to local authorities, or by regional Public Health England (PHE) teams for those linked to outbreaks. 
Since October, the proportion of people reached by regional PHE teams has accounted for a very small proportion 
(1% – 5%) of all cases covered by tracing.
16	 Between January and March 2021, because of high infection levels, NHST&T suspended the existing requirement 
for a confirmatory PCR test to trigger tracing for LFDs carried out at public testing sites, so that during this period a 
positive LFD result alone would trigger contact tracing. Confirmatory PCR tests were reinstated for these tests at the 
end of March. For LFD tests carried out elsewhere, the requirement for a confirmatory PCR test remained in place.
17	 This target was previously set at 80%, as noted in our interim report. Strictly, the target applies only to cases 
managed by the national service, excluding the small percentage covered by the regional PHE teams.
18	 This includes cases covered by national tracers, online channels, and hard to reach cases passed to 
local authority teams.
19	 Contacts are managed either by NHST&T’s national tracing service, or regional PHE teams if the original case 
is linked to an outbreak. Since the end of October, the proportion managed by regional health teams has been 
consistently low, varying between <1% and 8%.
20	 Strictly, the target applies only to contacts managed by NHST&T, excluding the small percentage covered by 
the regional PHE teams, but the trend including or excluding these cases is the same.

54  Part Three  Test and trace in England – progress update
Figure 19
People transferred to the COVID-19 contact tracing system and percentage of people reached 
in England week commencing 28 May 2020 to 29 April 2021
Numbers of people transferred to the contact tracing system peaked during December and has since reduced
0
10
20
30
40
50
60
70
80
90
100
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
450,000
Percentage of people (%)
Number of people
28 May
4 Jun
11 Jun
18 Jun
25 Jun
2 Jul
9 Jul
16 Jul
23 Jul
30 Jul
6 Aug
13 Aug
20 Aug
27 Aug
3 Sep
10 Sep
17 Sep
24 Sep
1 Oct
8 Oct
15 Oct
22 Oct
29 Oct
5 Nov
12 Nov
19 Nov
26 Nov
3 Dec
10 Dec
17 Dec
24 Dec
31 Dec
7 Jan
14 Jan
21 Jan
28 Jan
4 Feb
11 Feb
18 Feb
25 Feb
4 Mar
11 Mar
18 Mar
25 Mar
1 Apr
8 Apr
15 Apr
22 Apr
29 Apr
Week commencing
2020
2021
Total number of people transferred to contact tracing system
Percentage of people transferred to the system and reached
Note
1 
These fi gures refer to cases managed by the NHS Test and Trace Service, which includes hard to reach cases passed to local authorities, 
as well as cases managed by regional Public Health England teams.
Source: National Audit Offi ce analysis of data published by the Department of Health & Social Care

Test and trace in England – progress update  Part Three  55 
Percentage reached in under 24 hours
Percentage reached between 24 and under 48 hours
 Percentage reached between 48 and under 72 hours
Percentage reached after 72 hours
Note
1 
These fi gures refer to cases managed by the NHS Test and Trace Service which includes hard to reach cases passed to local authorities.
Source: National Audit Offi ce analysis of data published by the Department of Health & Social Care
Figure 20
Time taken to reach people testing positive for COVID-19, in England week commencing 
28 May 2020 to 29 April 2021
The percentage of people reached within 24 hours who had tested positive for COVID-19 increased between November and April
0
10
20
30
40
50
60
70
80
90
100
Percentage of people reached (%)
28 May
4 Jun
11 Jun
18 Jun
25 Jun
2 Jul
9 Jul
16 Jul
23 Jul
30 Jul
6 Aug
13 Aug
20 Aug
27 Aug
3 Sep
10 Sep
17 Sep
24 Sep
1 Oct
8 Oct
15 Oct
22 Oct
29 Oct
5 Nov
12 Nov
19 Nov
26 Nov
3 Dec
10 Dec
17 Dec
24 Dec
31 Dec
7 Jan
14 Jan
21 Jan
28 Jan
4 Feb
11 Feb
18 Feb
25 Feb
4 Mar
11 Mar
18 Mar
25 Mar
1 Apr
8 Apr
15 Apr
22 Apr
29 Apr
Week commencing
2020
2021

56  Part Three  Test and trace in England – progress update
Number of close contacts identified
Percentage of close contacts reached
Changes in rules for reaching household contacts
Notes
1 
These fi gures refer to close contacts managed by the NHS Test and Trace Service (NHST&T) which includes those passed to local authorities, 
and close contacts managed by regional Public Health England teams.
2 
NHST&T made changes to how it recorded the household contacts it reached between 18 November and 27 November. Where household contacts 
were previously contacted individually by contact tracers, they were now deemed as reached if the original case provided basic information and 
agreed to tell them to self-isolate. 
Source: National Audit Offi ce analysis of data published by the Department of Health & Social Care
Figure 21
Total number of close contacts identifi ed, and the percentage of close contacts reached, 
week commencing 28 May 2020 to 29 April 2021
The percentage of close contacts reached increased significantly during November 2020, in part due to changes in counting 
when household contacts are reached
0
10
20
30
40
50
60
70
80
90
100
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
28 May
11 Jun
25 Jun
9 Jul
23 Jul
6 Aug
20 Aug
3 Sep
17 Sep
1 Oct
15 Oct
29 Oct
12 Nov
26 Nov
10 Dec
24 Dec
21 Jan
7 Jan
4 Feb
18 Feb
4 Mar
18 Mar
1 Apr
15 Apr
29 Apr
Percentage of close contacts reached (%)
Number of close contacts
Week commencing
2020
2021

Test and trace in England – progress update  Part Three  57 
3.11	 NHST&T committed to reaching contacts faster in its December 2020 
business plan. Based on weekly performance data, NHST&T’s timeliness in reaching 
contacts improved from November to December 2020 but has since declined 
slightly. The metrics on the timeliness of reaching contacts are also affected by the 
November change in counting household contacts as reached (see paragraph 3.10). 
Following this change, for example, the proportion of contacts reached by the 
national service within 24 hours of the original case being transferred to contact 
tracing stood at 76% at the start of December. This increased to a peak of 79% 
in the middle of December, but subsequently declined, down to 53% for the 
last week of April 2021 (Figure 22 overleaf).
Measuring the effectiveness of the overall system
3.12	 The performance data published weekly on test and trace are helpful in 
understanding levels of activity and how well different parts of the test and 
trace process are working. However, as noted by the UK Statistics Authority in 
February 2021, they do not provide a clear view of the end-to-end effectiveness 
of the test and trace programme.21
3.13	 In May 2020, the UK Scientific Advisory Group for Emergencies (SAGE) 
provided advice about the proportion of infected individuals and their contacts that 
would need to be reached, and in what timeframe, for a test and trace system to be 
effective. Our review of this and other sources confirms that the key determinants 
of effectiveness are the speed of the process; levels of access and reach; and 
public adherence and engagement (Figure 23 on pages 55 and 56). Test and 
trace programmes are also more effective when overall infection levels are low 
and when they are able to target actions and interventions, particularly where 
different groups have higher risks or levels of transmission. These factors are 
not all necessarily within NHST&T’s direct control.
Effectiveness – speed of the process
3.14	 As noted in Figure 23, SAGE advises that, for test and trace to be effective, 
it is desirable that no more than 48 hours should elapse between identification of 
an index case and their contacts self-isolating. In May 2020, it had also noted that 
modelling suggested that any delay beyond 48–72 hours total before isolation of 
contacts resulted in a significant impact on the R number (the average number 
of people infected by someone with the virus), so the sooner done the better. 
An international systematic review in July 2020 found that to stop the spread 
of COVID-19, no more than 2–3 days should elapse from a new case developing 
symptoms to the isolation of the case and quarantine of at least 80% of associated 
contacts (‘cough to contact’ time). This explicitly includes the start of the process, 
before an individual engages with a test and trace system.
21	 From written evidence provided to the Public Administration and Constitutional Affairs Committee, available at: 
https://uksa.statisticsauthority.gov.uk/submission/uk-statistics-authority-and-office-for-statistics-regulation-written-
evidence-for-the-public-administration-and-constitutional-affairs-committee-inquiry-on-data-transparency-and-
accountability-covid/

58  Part Three  Test and trace in England – progress update
 Percentage of people reached  within 24 hours
Percentage of people reached between 24 hours and under 48 hours
 Percentage of people reached between 48 hours and under 72 hours 
 Percentage of people reached after 72 hours
Changes in rules for reaching household contacts
Notes
1 
These fi gures refer to close contacts managed by the NHS Test and Trace Service, including those passed to local authorities. 
2 
Time taken is between an identifi ed contact being transferred to the contact tracing system and the contact being reached and advised to self-isolate.
3 
The NHS Test and Trace Service made changes to how it recorded the household contacts it reached between 18 November 2020 and 
27 November 2020. Where household contacts were previously contacted individually by contact tracers, they were now deemed to have been 
reached only if the original case provided basic information and agreed to tell them to self-isolate.  
Source: National Audit Offi ce analysis of data published by the Department of Health & Social Care
Figure 22
Time taken to reach close contacts of cases, in England week commencing 28 May 2020 to 
29 April 2021
The percentage of close contacts reached within 24 hours peaked during December
0
10
20
30
40
50
60
70
80
90
100
28 May
4 Jun
11 Jun
18 Jun
25 Jun
2 Jul
9 Jul
16 Jul
23 Jul
30 Jul
6 Aug
13 Aug
20 Aug
27 Aug
3 Sep
10 Sep
17 Sep
24 Sep
1 Oct
8 Oct
15 Oct
22 Oct
29 Oct
5 Nov
12 Nov
19 Nov
26 Nov
3 Dec
10 Dec
17 Dec
24 Dec
31 Dec
7 Jan
14 Jan
21 Jan
28 Jan
4 Feb
11 Feb
18 Feb
25 Feb
4 Mar
11 Mar
18 Mar
25 Mar
1 Apr
8 Apr
15 Apr
22 Apr
29 Apr
Percentage of close contacts reached (%)
Week commencing
2020
2021

Test and trace in England – progress update  Part Three  59 
Figure 23
National Audit Offi ce review of key determinants of the effectiveness of test and trace approaches 
for COVID-19
Our review found that the key determinants of effectiveness are the speed of the process, levels of access and reach, and public 
adherence and engagement
Key factors and characteristics determining the 
effectiveness of the test and trace approach 
Indicative thresholds or targets
Speed of the 
process
It is important to minimise the time between 
someone developing symptoms and their contacts 
being reached and asked to self-isolate. This will 
include how long it takes for someone who might 
be infected with COVID-19 to request a test, 
self-isolate, get tested and then get the results; 
and for their contacts to be identified and traced.
In May 2020, SAGE advised that, for test and trace to 
be effective, it is desirable that no more than 48 hours 
should elapse between identification of an index case 
and their contacts self-isolating. A systematic review in 
July 2020 found that to stop the spread of COVID-19, 
no more than 2–3 days should elapse from a new case 
developing symptoms to the isolation of the case and 
quarantine of at least 80% of associated contacts. These 
are consistent with the optimum time noted by the World 
Health Organization. 
For in-person tests, the NHS Test and Trace Service 
(NHST&T) has a target of 80%, where the time taken from 
ordering a test to reaching contacts is within 48 hours 
(two days). Prior to March 2021, the target was 80% 
within 72 hours.
Levels of access 
and reach 
It is important to maximise the number/proportion 
of people with COVID-19 that the system reaches, 
along with their associated contacts. How access 
and reach vary for different groups in the 
population is also important, as they may have 
different levels of infections or risk of transmission. 
Linked to this will be the system having adequate 
capacity and capability to cope with demand.
SAGE has noted that “at least 80% of contacts of an 
index case would need to be contacted for a system to be 
effective”, which is broadly consistent with the systematic 
review we examined.
NHST&T has targets to reach at least 90% of index 
cases, and 85% of contacts. It also aims to identify 60% 
of new infections through testing.
Public 
adherence and 
engagement
This is particularly important in terms of people 
complying with requirements to self-isolate. 
However, other parts of the test and trace process 
also rely on high levels of public adherence, for 
example people having a test when required or 
agreeing to give details of contacts. This links to 
maintaining public awareness, understanding and 
acceptance of the system and what individuals 
need to do.
SAGE has noted that “at least 80% of contacts of an 
index case would need to isolate for an effective test and 
trace system”. The systematic review identified that for a 
highly effective system, quarantine and isolation would 
need to prevent 100% of further transmissions.
NHST&T currently has no target in relation to compliance 
with self-isolation.

60  Part Three  Test and trace in England – progress update
3.15	 Published information is now available for NHST&T, based on individual 
contacts, on the time elapsing between a case developing symptoms and that 
contact being reached.22 Before mid-November 2020, the median time for this 
was consistently above 100 hours, although it reduced to 80 hours following the 
change in rules for counting household contacts as reached (Figure 24).23 It then 
rose to a peak of around 120 hours at the end of December, before reducing again; 
for each week starting 14 January to 29 April 2021, it has varied between 74 and 
97 hours. This means that, for most contacts in this period, more than 72 hours 
elapsed before they were reached. NHST&T told us that longer turnaround times in 
April were partly due to an increase in the proportion of non-household contacts, 
who are harder to trace. In April, the proportion of non-household contacts made 
up around half or more of all contacts traced, compared with around one-quarter 
to one‑third in March.
22	 This is only available for contacts of cases who reported symptoms to NHST&T. It is based on individual, rather 
than all, identified contacts for a case. This means that the median time to reach all contacts of a case would be 
the same or greater than implied by this measure, as it would have to reflect the elapsed time for the last contact 
to be reached.
23	 See paragraph 3.10 for details of the changes in counting of household contacts.
Other factors and characteristics determining the effectiveness of the test and trace approach
Targeting 
of actions/ 
interventions
An important role of the test and trace system is how quickly it can identify potential outbreaks, and escalate 
actions and capacity where needed.
In relation to mass (asymptomatic) testing, SAGE has also noted that “some groups contribute more to the 
spread of the epidemic than others [so] targeting groups and institutions where prevalence is likely to be higher 
will have a greater impact on transmission”.
Overall levels 
of infections
In general, test and trace strategies for COVID-19 are not effective on their own, but must be used alongside 
other public health interventions, for example vaccinations, social distancing and good hygiene, to reduce 
infections. Test and trace strategies are most effective when overall infection levels are low, and exhaustive 
tracing of cases and contacts is possible. The systematic review we examined found that the effectiveness of 
contact tracing could stop the spread with five or fewer initial cases in the community, but with 40 or more cases, 
might not contribute meaningfully to stopping infections.
Note
1 
 The following sources were included in our review: minutes from the UK Scientifi c Advisory Group for Emergencies (SAGE) between April 2020 and 
March 2021, including relevant papers from the Scientifi c Pandemic Infl uenza Group on Modelling (SPI-M); World Health Organization, Contact tracing 
in the context of COVID-19, Interim Guidance, 1 February 2021; The Association of Directors of Public Health, Explainer: Test and Trace Service, 
October 2020; Scottish Government, COVID-19 – Test, Trace, Isolate, Support. A Public Health approach to maintaining low levels of community 
transmission of COVID-19 in Scotland, May 2020; Juneau, C., Briand, A., Pueyo, T., Collazzo, P. and Potvin, L., Effective Contact Tracing for COVID-19: 
A Systematic Review, July 2020, available at: www.medrxiv.org/content/10.1101/2020.07.23.20160234v2.full.pdf.
Source: National Audit Offi ce review of published information
Figure 23 continued
National Audit Offi ce review of key determinants of the effectiveness of test and trace approaches 
for COVID-19

Test and trace in England – progress update  Part Three  61 
Changes in rules for reaching household contacts
Median time taken in hours
Notes
1 
The date for symptom onset is when the original case reports this to the NHS Test and Trace Service (NHST&T) 
after taking a positive test. This information is only available for contacts of cases who report to NHST&T that they 
have experienced one or more symptoms of COVID-19.
2 
Medium time in hours is derived using time in days and taking 12:00 noon as the time of symptom onset.
3 
NHST&T made changes to how it recorded the household contacts it reached between 18 November 2020 and 
27 November 2020. Where household contacts were previously contacted individually by contact tracers, they were 
now deemed as reached if the original case provided basic information and agreed to tell them to self-isolate.  
Source: National Audit Offi ce analysis of data published by the Department of Health & Social Care
Figure 24
Median time taken between the onset of symptoms in an individual and the 
NHS Test and Trace Service reaching an identifi ed contact, in England, weeks 
commencing 28 May 2020 to 29 April 2021
The time taken to reach contacts reduced between October 2020 and March 2021
0
20
40
60
80
100
120
140
160
180
28 May
18 Jun
2020
9 Jul
30 Jul
20 Aug
10 Sep
1 Oct
22 Oct
12 Nov
3 Dec
24 Dec
4 Feb
25 Feb
18 Mar
8 Apr
14 Jan
29 Apr
Median time from symptom onset of case to contact being reached (hours)
Week commencing
2021

62  Part Three  Test and trace in England – progress update
3.16	 For in-person tests, NHST&T also monitors an internal target of 80% of cases, 
where the time taken from ordering a test to reaching contacts is within 72 hours.24 
Its internal management information shows that it reached this target consistently 
from the start of January 2021. At the beginning of March, NHST&T strengthened 
this target to 80% within 48 hours; it met it during that month although performance 
dipped below target in April. This metric does not include the elapsed time between 
someone developing symptoms and requesting a test, which NHST&T says it has 
limited influence over. It also only includes in-person tests, which made up 37% 
of PCR tests taken in the community between May 2020 and April 2021. The 
proportion has also decreased, standing at 16% for March and April 2021. Examples 
of tests not counted as ‘in-person’ include home test kits or tests supplied to care 
homes for regular testing of staff and residents. We were not able to access data on 
what proportion of positive cases are identified via in-person versus other PCR tests.
Effectiveness – levels of access and reach
3.17	 In relation to levels of reach, SAGE has noted that “at least 80% of contacts 
of an index case would need to be contacted for a system to be effective”. 
NHST&T published targets to reach at least 90% of index cases, and 85% of their 
identified contacts by January 2021. NHST&T achieved the 90% target for cases 
for most weeks between mid-March 2021 and the end of April (paragraph 3.8). 
It has also exceeded the 85% target for identified contacts between the end of 
November 2020 and mid-April 2021, although performance dropped to 84% at 
the end of April (see paragraph 3.10).25
3.18	 As we noted in our interim report, testing and tracing systems typically suffer 
from attrition, meaning they are unable to identify everyone with a disease or 
all their close contacts. Our analysis suggested that, for COVID-19, the greatest 
attrition occurred at the start of the process, with people who have the infection 
but do not get a test. NHST&T has less direct influence over the very start of the 
process, before someone books a test. It has an internal target to identify 60% of 
new infections through testing. Up until November, it estimated this by combining 
its weekly data on positive cases with weekly estimates from the Office for 
National Statistics (ONS) of new infections. In our interim report, we used these 
data to calculate that around 44% of people with COVID-19 had a positive test 
by NHST&T, between 28 May and 4 November 2020.
3.19	 Between December 2020 and March 2021, ONS suspended its weekly data 
on new infections when it revised its methodology for calculating these. This means 
that NHST&T could not reliably assess how well its testing covered new infections 
for a critical period covering the December rise in infections and the introduction 
of mass LFD testing.
24	 SAGE has not specifically defined ‘identification of an index case’. For its target, NHST&T interpreted this as when 
someone ordered a test, the point at which it first becomes aware of a potential case.
25	 As noted in paragraph 3.10, this period reflected the new rules in counting household contacts as reached 
once the original case was contacted.

Test and trace in England – progress update  Part Three  63 
3.20	From 26 March 2021, ONS resumed publishing weekly data on new infections 
with a revised methodology. However, NHST&T’s initial review indicated that the 
new estimates still did not provide a reliable or stable means of calculating its key 
performance indicator. For example, our calculations showed that for several weeks, 
the total number of positive cases identified by NHST&T exceeds the revised ONS 
estimate of total new infections. This means that NHST&T still lacks a reliable means 
of calculating this key performance indicator. NHST&T is reviewing different options 
to produce a robust measure for the percentage of new infections identified through 
testing, and aims to achieve this by mid-June.
Effectiveness – public adherence and engagement
3.21	An academic review of Department of Health & Social Care (the Department) 
– funded surveys on public adherence notes the reliance of test, trace and isolation 
systems on “how well people adhere to guidance on testing, provide details of 
contacts, and self-isolate”.26 In particular, high levels of compliance with self-isolation 
are needed: SAGE has noted that “at least 80% of contacts of an index case would 
need to isolate for an effective test and trace system” (see Figure 23). NHST&T 
currently has no target in relation to compliance with self-isolation.
3.22	Scientific experts have noted the need to consider behavioural issues for 
the test and trace system, and that key levers available to NHST&T to encourage 
desirable behaviour include providing clear and consistent messaging through 
public health information that emphasises the social value of testing and frames 
compliance as the ‘right thing to do’. The Independent Scientific Pandemic Insights 
Group on Behaviours (SPI-B), which advises SAGE, has also noted the importance 
of addressing practical and psychological barriers to self-isolation, including through 
financial support. NHST&T confirmed to us that it has a responsibility to encourage 
people to both come forward for testing and to isolate if they test positive, but that it 
is also the responsibility of the individual to comply. Several stakeholders we spoke 
to highlighted that the extent of citizens’ compliance with NHST&T’s requirements 
was a significant risk it must actively manage.
26	 Smith. L. E., Potts, H. W. W., Amlôt, R., Fear, N. T., Michie, S., Rubin, G. J., Adherence to the test, trace, and 
isolate system in the UK: results from 37 nationally representative surveys, The BMJ, volume 372, March 2021, 
available at: https://doi.org/10.1136/bmj.n608

64  Part Three  Test and trace in England – progress update
3.23	Several different survey-based measures are available on specific aspects of 
public adherence with the test and trace process (Figure 25). The surveys suggest:
•	
only a minority of people who develop symptoms request a test. The University 
College London study found that older people, men, and people in 
lower-income households were consistently less likely to request a test 
following symptoms;
•	
there is a wide range in estimated levels of compliance with self-isolation for 
people who develop COVID-19 symptoms in part explained by differences in 
the survey measures. In surveys by ONS, based on samples from NHST&T’s 
contact tracing database, 82% to 86% of respondents said they fully 
adhered to the self-isolation requirements. Other surveys, based on the wider 
population, which include people whether or not they definitely have COVID-19, 
have taken a test or engaged with the test and trace system, suggest lower 
compliance levels, ranging from 43% to 62%.27 The CORSAIR study identified 
a number of socio-demographic characteristics associated with lower levels 
of compliance, including: being male, younger, having a dependent child in 
the household, lower socioeconomic grade, greater financial hardship during 
the pandemic, and working in a key sector; and
•	
a high level of compliance with self-isolation after being notified as a 
contact of someone infected with COVID-19.
Estimating the overall impact of test and trace
3.24	It is inherently difficult to establish the impact that NHST&T activities by 
themselves have on reducing transmission, as they were implemented nationally 
in a short space of time in conjunction with a range of other measures intended 
to reduce infections, such as social distancing, wearing masks and vaccinations. 
NHST&T has published, and worked with external experts to produce, modelled 
estimates of the impact of its activities. As with any model, the estimates will depend 
on the structure of the model, the counterfactual being used (broadly, what would 
have happened in the absence of test and trace activities), and assumptions about 
the value of key parameters (for example, compliance levels with self-isolation 
or the proportion of cases that present symptoms). We reviewed a number of 
published and internal analyses, which set out findings, technical descriptions 
and assumptions for these models. Below we set out findings for these models, 
including observations from our own review.
27	 These ask whether respondents left home at all during the self-isolation period (which is permissible under 
certain circumstances).

Test and trace in England – progress update  Part Three  65 
Figure 25
Survey-based measures of public adherence and compliance with different stages of the test, trace and isolate process
These measures suggest compliance with the test and trace process varies across its different stages
Stage
Source
Based on
Measure
Level
Date
Requesting a test after 
developing symptoms
CORSAIR
Adults aged 16+ in the UK, who 
reported experiencing COVID-19 
symptoms in the past seven days 
Requested a test 
18%
May 2020 to January 2021
22%
January 2021 
(most recent measure)
UCL
Adults in the UK, who reported 
developing COVID-19 symptoms 
since the pandemic started 
Requested a test 
33% every time, 10% on some 
occasions but not others
March 2020 to January 2021
Compliance with 
self-isolation – people 
developing symptoms
CORSAIR
Adults aged 16+ in the UK who 
reported experiencing COVID-19 
symptoms in the past seven days
Not leaving home for any 
reason in the fi rst 10 days 
after symptoms developed
43% 
October 2020 to January 2021
52%
January 2021 
(most recent measure)
UCL
Adults in the UK, who reported 
developing symptoms 
of COVID-19
How many days isolating
62% for 10 days or more
March 2020 to January 2021
ONS 
(experimental 
statistics)
Individuals aged 18+ on 
NHST&T’s contact tracing 
database, who had tested 
positive for COVID-19
Fully adhering to the 
self-isolation requirements 
throughout their 
self-isolation period
82% – 86%
February 2021, March 2021, 
April 2021
Compliance with 
self-isolation – people 
potentially in contact 
with COVID-19
UCL
Adults in the UK, who were told 
they had come into contact 
with someone else who had 
developed symptoms 
How many days isolating 
80% for 10 days or more
March 2020 to January 2021
ONS 
(experimental 
statistics)
Individuals aged 18+ on 
NHST&T’s contact tracing 
database, who were notifi ed 
by NHST&T they had been in 
contact with someone testing 
positive for COVID-19
Fully adhering to the self-
isolation requirements 
throughout their 10-day 
self-isolation period
90%
March 2021, April 2021
Notes
1 
 CORSAIR study: Smith. L. E., Potts, H. W. W., Amlôt, R., Fear, N. T., Michie, S., Rubin, G. J., Adherence to the test, trace, and isolate system in the UK: results from 37 nationally 
representative surveys, The BMJ, volume 372, March 2021. Based on series of cross-sectional surveys, using quota samples. Sample sizes for: (a) requesting a test: 3068 (all waves), 
117 (January 2021); (b) compliance with self-isolation requirements: 1213 (all waves); 83 (January 2021).
2 
 UCL: University College London, COVID-19 Social Study, Results Release 28, January 2021. For compliance measures, respondents provided the shortest time they had isolated if they had 
been required to self-isolate more than once as a case or contact. Based on volunteer sample. More than 70,000 respondents in total, but sample sizes for these analyses not published.
3 
 ONS (experimental statistics): Offi ce for National Statistics, Statistical Bulletins on Coronavirus and self-isolation after testing positive in England, February–April 2021, and Statistical 
Bulletins on Coronavirus and self-isolation after being in contact with a positive case in England, March–April 2021. ONS notes that as the statistics are experimental, care needs to be taken 
in interpreting them. Based on  random samples of cases and contacts. Based on random samples from NHS Test and Trace Service (NHST&T) contact tracing database. Range of sample 
sizes per wave: (a) for people testing positive: 1,122 to 1,168 (response rates of 16% – 17%); (b) for notifi ed contacts = 1,100 to 1,212 (response rates of 17% – 19%).
Source: National Audit Offi ce review of published survey measures

66  Part Three  Test and trace in England – progress update
3.25	In February 2021, NHST&T published the findings of an initial model analysis, 
which assessed the impact of test, trace and isolate on COVID-19 transmission 
(the R number).28 This estimated that, in October 2020, the combination of testing, 
tracing and self-isolation resulted in a reduction in the R number of 18% – 33%. 
Self-isolation upon onset of symptoms by individuals accounted for most of 
this reduction, 16% – 28%, with the impact of contact tracing activities alone 
estimated at 2% – 5%. NHST&T is planning to publish an updated model by 
the end of June 2021, to cover the period May 2020 to May 2021, including the 
introduction of LFD tests.
3.26	Based on our review of the published information, we note a number of 
elements that, overall, could overstate the estimated contribution of NHST&T’s 
activities to reductions in transmission:
•	
The analysis notes that “the majority of [estimated] transmission reduction is 
due to isolation on symptoms”, which occurs before people engage with the 
test and trace system, and that the most infectious period is likely to have 
passed before someone receives a test result. It is therefore arguable the 
extent to which this component of the reduction can be attributed to NHST&T’s 
activities. NHST&T highlighted that the analysis showed a correlation between 
engagement with test and trace, and compliance with self-isolation. However, 
how much people’s compliance is actually influenced by test and trace 
activity is still very difficult to gauge;
•	
In estimating the impact of NHST&T’s activities, it compares this to a scenario 
with only social distancing and no self-isolation, that is, it assumes no one 
would self-isolate of their own accord if they were to develop symptoms. 
Any departure from this assumption would reduce the estimated impact. 
NHST&T noted that it was difficult to make alternative comparisons, given 
a lack of information on levels of compliance with isolation when people 
do not have a test; and
•	
Like any model, the estimates are highly dependent on a number of 
assumptions, which are set out in additional technical information published 
by NHST&T. The model was also subject to external review, which “regarded 
the core assumptions and structure as appropriate given the constraints”. 
Our review noted that while many of the assumptions are based on 
the best available data, some may be over-optimistic, for example the 
assumption that there is no overlap between people’s contacts.
28	 The R number is the average number of people infected by someone with the virus.

Test and trace in England – progress update  Part Three  67 
3.27	The Department also funded a study which evaluated the impact of the NHS 
COVID-19 app on reducing transmissions using two different models.29 The app 
helps reduce transmission through automated notifications to app users who have 
come into close contact with another app user who has tested positive. The study 
estimated that, between October and December 2020, approximately 100,000 
to 900,000 cases could have been prevented by the app. During the period 
modelled for the app, there were 1.89 million reported COVID-19 cases. As noted 
in the peer‑reviewed published papers, there are some inherent uncertainties and 
limitations with the data used and therefore the estimates from the models, as 
reflected in the large range in the estimates of cases prevented.
3.28	NHST&T also highlighted research that had been carried out into the impact 
of asymptomatic testing on the infection rate within schools during March 2021. 
We reviewed a preliminary report of this research, although this did not include 
details of the methods or main assumptions. The report noted a steady increase 
in the number of secondary school aged pupils testing positive by LFD tests 
during the first three weeks that schools were open. It produced “preliminary and 
qualitative” model estimates that LFD testing may have reduced infection by up 
to 30% in secondary school pupils, compared with a scenario based on isolation 
of close contacts alone. The paper noted that the link between secondary school, 
and wider community transmission, was unclear.
Accessibility and diversity
3.29	In our interim report, we noted that the Department had identified that certain 
disadvantaged groups could have difficulties in accessing test and trace services 
and it had taken some steps to address these. NHST&T’s December 2020 business 
plan set out aims to increase reach among disadvantaged and less visible groups, 
translate more guidance nationally, and to make user experiences simpler, easier and 
more convenient. It has also developed an internal Equity and Inclusion Strategy.
3.30	NHST&T noted measures it had taken since October 2020 include undertaking 
research to improve understanding of groups disproportionately impacted by 
self‑isolation; partnering with the Royal National Institute of Blind People to improve 
the experience of blind and partially sighted people; providing more translation and 
interpretation services; and running targeted campaigns to raise awareness of lateral 
flow testing amongst higher risk groups. NHST&T’s internal management reporting 
also includes some limited metrics and performance indicators to track diversity and 
inclusion. However, gaps remain for certain groups, and it has identified evidence 
of systemic bias in some data collection methods. NHST&T told us it was exploring 
additional data collection, which would allow it to measure service performance 
and outcomes for areas and population groups of interest.
29	 Wymant, C., Ferretti, L., Tsallis, D. et al. The epidemiological impact of the NHS COVID-19 app. Nature 594, 
408–412 (2021). Available at: https://doi.org/10.1038/s41586-021-03606-z. The analysis included both 
epidemiological and statistical modelling.

68  Part Three  Test and trace in England – progress update
3.31	Analyses by ONS and Public Health England indicate that some groups 
may have a higher number of COVID-19 infections and COVID-19-related deaths, 
with variations observed, for example, by ethnic group and levels of deprivation.30 
Many factors such as previous underlying health conditions could contribute 
to unequal outcomes. NHST&T already collects some data that can be used to 
understand whether differences in access to test and trace services for vulnerable 
groups exist, and if so, how they could be contributing to the poorer outcomes 
for these groups. We have seen a range of in-depth analysis by NHST&T on 
levels of infections or number of outbreaks by age groups, geographic locations 
or for particular settings, for example workplaces and care homes. It has also 
undertaken limited analysis of the number of lateral flow tests registered by men 
and ethnic minority groups. However, we are not aware of any systematic analysis 
on differences in access to symptomatic testing and tracing services by vulnerable 
groups and whether this has affected their outcomes. Several stakeholders we 
spoke to expressed concern about lower levels of testing among minority ethnic 
groups or for those living in deprived areas and the particular challenges they 
faced in adhering to self‑isolation.
3.32	There have been wide and unexplained variations in the number of tests and 
proportion of people testing positive for COVID-19 by local authority. Between 
May 2020 and April 2021, the number of tests carried out ranged from 0.8 to 2.5 
tests per person, while the proportion of people testing positive ranged from 
1% – 13%. It is not clear how variations in access to testing and the performance of 
test and trace have impacted on variations in the level of infections. Our exploratory 
analysis suggested that local authorities with lower levels of testing tended to 
have higher proportions of people testing positive for COVID-19. We did not find a 
clear relationship between numbers of tests carried out and levels of deprivation. 
However, we note that a small number of areas – Oldham, Blackburn, Bradford, 
Bolton, which all have a high level of deprivation – persistently have a higher 
level of infection than most other parts of the country.
30	 Office for National Statistics, articles on Updating ethnics contrasts in deaths involving the coronavirus (COVID-19), 
England, available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/
articles/updatingethniccontrastsindeathsinvolvingthecoronaviruscovid19englandandwales/previousReleases
	
Office for National Statistics, Coronavirus (COVID-19) Infection Survey: characteristics of people testing positive 
for COVID-19 in England and antibody data for the UK: December 2020, 14 December 2020, available at: 
https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/
coronaviruscovid19infectionsinthecommunityinengland/december2020
	
Public Health England, Beyond the data: Understanding the impact of COVID-19 on BAME groups, June 2020; 
Disparities in the risk and outcomes of COVID-19, August 2020. It also regularly updates variations in infection levels 
for different ethnic groups in its National flu and COVID-19 surveillance reports, available at: https://www.gov.uk/
government/statistics/national-flu-and-covid-19-surveillance-reports

Test and trace in England – progress update  Part Four  69 
Part Four
Future plans for the NHS Test and Trace Service
4.1	
There are many uncertainties about both the medium and longer-term future, 
including the impact of the vaccine on COVID-19 prevalence and transmission, 
as well as the impact of new variants of COVID-19. NHS Test and Trace (NHST&T) 
therefore faces significant challenges in planning for the future, including 
managing various competing demands. It needs to:
•	
plan for a range of scenarios which could involve an overall reduction 
in infection levels, while at the same time managing the risk of localised 
outbreaks or an overall resurgence of COVID-19;
•	
plan and deliver structural changes as it prepares to merge with other 
bodies and transition to the new UK Health Security Agency (UKHSA) by 
October 2021, while at the same time continuing its efforts to contain the 
spread of the virus; and
•	
establish how it will deliver its commitment to secure long-term benefits from 
its investment in testing infrastructure, including preparedness for future 
infectious diseases and early diagnostics for other diseases.
4.2	 This section covers NHST&T’s future plans, including:
•	
its approach to testing and tracing, including its operating model and testing 
and tracing capacity;
•	
arrangements for transitioning to the new UKHSA and key risks that we, 
NHST&T and stakeholders have identified; and
•	
plans for securing benefits from the laboratory infrastructure it has established.

70  Part Four  Test and trace in England – progress update
NHST&T’s plans for its approach to testing and tracing
The operating model
4.3	 NHST&T has acknowledged that it needs to determine what its operating model 
will look like if COVID-19 prevalence reduces and outbreaks become more localised. 
Local stakeholders told us there is uncertainty about the roles that national, regional 
and local bodies will play, what the structure will look like as NHST&T transitions 
into UKHSA, and the future resourcing model given the need to respond flexibly 
to local outbreaks.
4.4	 Stakeholders we spoke to highlighted the need for a clearer whole-system plan 
for test, trace and isolate and a more consistent approach. One stakeholder told us 
there is no recovery plan, although these would normally be put in place during a 
public health incident. We also heard that NHST&T policies on test, trace and isolate 
often operate in isolation from each other. Some local initiatives are providing more 
joined-up and citizen-focused ways of working, such as by providing information on 
self-isolation support at testing centres.
4.5	 In February 2021, NHST&T’s Executive Committee noted that national and 
local areas needed to provide a more integrated service that aligned data, people 
and assets. Local stakeholders told us that joint working between national and 
local bodies has improved. However, they also noted that despite a willingness for 
national and local integration at senior levels within NHST&T, there is sometimes a 
reluctance on the ground to give responsibilities to local partners. We also heard 
that local authorities sometimes find it difficult to respond quickly and effectively 
to incidents due to having insufficient powers under legislation.
Understanding the need for testing and tracing
4.6	 NHST&T is working in a very uncertain environment and it is difficult to 
make predictions about the future prevalence of COVID-19 (see paragraph 4.1). 
However, we have seen evidence that NHST&T has sought to improve its 
understanding of the need for testing and tracing:
•	
NHST&T told us that to forecast the need for testing and tracing, it now 
undertakes modelling using historical data and information on prevalence. 
It considers that this has enabled it to forecast need with more precision, 
although we have not reviewed its model.
•	
In December 2020, it used models to assess the likely impact of the vaccine 
on the need for test and trace activities using four scenarios. These looked at 
different scenarios for vaccine impact, including its effect on new infections, 
transmission and symptoms, as well as the uptake and length of time for 
which it provides immunity.

Test and trace in England – progress update  Part Four  71 
4.7	 NHST&T’s analysis, which was based on data produced by the Scientific 
Pandemic Influenza Group on Modelling (SPI-M), indicates that the need for test 
and trace activities would be different in each of the four scenarios it considered 
(Figure 26 overleaf). It told us that the data indicated that there would be another 
surge in COVID-19 cases with varying timings and it is working on the assumption 
that the surge will occur in autumn 2021.
Plans for future testing and tracing capacity
4.8	 Where there is uncertainty about a service need, it is important to build 
flexibility into plans to be able to respond to sudden surges in demand. Our previous 
report found that the Department of Health & Social Care’s (the Department’s) 
contracts to provide call handlers for tracing had no provision to vary the staffing 
levels in the first three months. However, the Department quickly became aware 
that it had purchased excess capacity.31 This section looks at NHST&T’s capacity 
plans for symptomatic testing, tracing and asymptomatic testing, including 
building flexibility into these plans.
Plans for symptomatic testing capacity
4.9	 NHST&T plans to retain its laboratory capacity in 2021-22, whilst building in 
flexibility to respond to surges in need. It is planning to:
•	
increase the maximum theoretical capacity in privately-owned Pillar 2 
laboratories to 760,000 tests a day in 2021-22, from 477,000 tests a day 
on 31 March 2021. It expects laboratories to operate at up to 80% of this 
theoretical capacity (equivalent to 608,000 tests a day);
•	
retain capacity in Pillar 1 laboratories, comprising 12,500 tests a day in 
Public Health England (PHE)-owned laboratories, 67,000 tests a day in NHS 
owned laboratories in England as well as capacity provided by the devolved 
administrations. In addition, the NHS has also committed to process 33,000 
rapid point of care tests each day for the financial year 2021-22 under Pillar 1. 
It is easier to use these laboratories for other purposes if the capacity is not 
needed, and NHST&T is reviewing how they could be used without incurring 
high extra costs; and
•	
create capacity in the new Leamington Spa laboratory, which is due to start 
processing samples in June 2021 and is expected to have an operating 
capacity of 200,000 tests a day when fully operational in autumn 2021.
31	 Comptroller and Auditor General, The government’s approach to test and trace in England – interim report, 
Session 2019–2021, HC 1070, National Audit Office, December 2020.

72  Part Four  Test and trace in England – progress update
Figure 26
NHS Test and Trace Service analysis from December 2020 of the impact of the COVID-19 vaccine on the need for test and 
trace activities, using four possible scenarios
NHS Test and Trace Service analysis of the impact of the COVID-19 vaccine shows that the need for test and trace activities would be different in each of the 
four scenarios it considered 
Scenario description
Implications for NHS Test and Trace Service
Symptomatic 
testing
Non-symptomatic testing
Laboratory capacity
National and local 
contact tracing 
Surveillance 
Vaccine effectively reduces the 
transmission and symptoms 
of COVID-19. There is a 
high vaccine uptake and 
permanent immunity
Demand 
reduces 
Could be scaled back, 
reprioritised or removed 
Can be significantly 
reduced or repurposed 
Option to relocate 
resources meant for 
national contact tracing 
and reduce resourcing 
for local contact tracing
Helpful for 
managing flare-ups, 
including anti-body 
testing
Vaccine effectively reduces the 
transmission of COVID-19 but 
not the symptoms. There is a 
moderate vaccine uptake and 
immunity window
Demand 
reduces
Could be scaled back, 
although option to retain 
in non-vaccinated groups 
Can be reduced 
or repurposed 
Cases and unvaccinated 
contacts fall 
Could be needed 
to protect 
non-vaccinated 
groups 
Vaccine effectively reduces 
COVID-19 symptoms, but 
transmission remains high. 
There is a moderate vaccine 
uptake and immunity window
Demand 
reduces 
There could be an 
increased need, 
for example, in 
non-vaccinated groups
Can be reduced or 
repurposed. Laboratory 
operating model could 
change, for example, 
to prioritise volume 
over speed
Increased asymptomatic 
case finding
Would be critical 
for protecting 
non-vaccinated 
groups, including 
antibody testing
Vaccine has minimal impact on 
transmission and symptoms. 
Low vaccine uptake and short 
immunity window
Demand 
unchanged 
There could be an 
increased need, 
for example, in 
non-vaccinated groups
Cannot be reduced
Cases and contacts 
remain high
Need for 
surveillance limited 
by enduring high 
case rate 
Notes
1 
NHS Test and Trace Service’s (NHST&T’s) scenario analysis is based on data published by the Scientifi c Pandemic Infl uenza Group on Modelling (SPI-M). 
2 
Symptomatic testing refers to the testing of people with symptoms of COVID-19. It is carried out using polymerase chain reaction (PCR) tests, which are processed in laboratories 
and test for the presence of the COVID-19 virus using a swab.
3 
Asymptomatic testing refers to the testing of people without symptoms of COVID-19. Regular asymptomatic testing in social care is carried out using PCR tests but other asymptomatic 
testing is predominantly carried out using lateral fl ow device (LFD) tests. LFD tests give results in 30 minutes or less without the need for laboratory processing. 
4 
The surveillance technologies considered by NHS Test and Trace Service were wastewater analysis and antibody testing. 
Source: National Audit Offi ce analysis of NHS Test and Trace Service documents

Test and trace in England – progress update  Part Four  73 
4.10	 Laboratory capacity cannot be turned on or off at short notice, and there is a 
trade-off between having the flexibility to change capacity at short notice and cost. 
NHST&T told us that it has introduced more flexibility into 2021-22 contracts to be 
able to flex volumes. It told us that there are several options for building capacity, 
including increasing staff and equipment in Lighthouse labs to make use of dormant 
capacity (6-12 weeks lead-in times), or procuring surge capacity from the private 
sector (fast to secure but expensive).
Plans for tracing capacity
4.11	 NHST&T has not planned what central call handler capacity it will use in 
2021‑22 due to uncertainty about future prevalence. As at 8 March 2021, its current 
capacity levels were 15,300 people in total, including 4,600 Tier 2 specialists, and 
10,700 Tier 3 call handlers.
4.12	 Local stakeholders told us that there was a need to secure flexible resource 
capacity for local contact tracing, in case infection levels increase in the future. 
They noted that local capacity was being stretched and that much of the local 
COVID-19 response workforce were on temporary contracts, meaning it might be 
hard to retain and recruit people if the economy picks up.
Plans for asymptomatic tracing capacity
4.13	 NHST&T has not yet set out its medium to longer-term plans for asymptomatic 
testing, including if it will be needed in the future and by which sectors. It has noted 
that as prevalence reduces, asymptomatic testing could be limited to NHS and adult 
social care workers. However, it is not clear what factors or levels of prevalence 
would trigger a reduction in the need for testing. NHST&T’s budget for 2021-22 
includes provision for 21 million lateral flow device (LFD) tests a week. NHST&T 
has provided businesses with free workplace testing until at least 19 July, after 
which responsibility may transfer to businesses. It is considering if daily testing of 
the contacts of positive cases could be used as an alternative to self-isolation if 
the contacts test negative.
Transition to the UKHSA
4.14	 On 18 August 2020, government announced that a new body, the National 
Institute for Health Protection, would subsume NHST&T, including the Joint 
Biosecurity Centre (JBC), and the health protection functions of PHE. As announced 
on 24 March 2020, the new body, now renamed the UK Health Security Agency, 
was formally established in April 2021 to protect people from infectious diseases and 
external health threats. A new Office for Health Promotion, within the Department, 
is to be established in autumn 2021 to lead on promoting good health.

74  Part Four  Test and trace in England – progress update
4.15	 The Department expects UKHSA to be fully operational from 1 October 2021, 
at which point all staff that are due to move from NHST&T, PHE and the Department 
will transfer to UKHSA. The Department expects that by October, IT systems, data, 
contracts, estates and all other accompanying functions will also transfer from the 
Department and PHE to UKHSA, allowing PHE to move into a close-down phase. 
Final details on the design, structure and expected outcomes of UKHSA are due 
in autumn 2021. A chief executive and separate chair was appointed to UKHSA in 
April 2021 and the post of executive chair of NHST&T ended in April 2021.
4.16	 The transition of NHST&T to UKHSA brings several risks and challenges:
•	
The need to plan and implement the restructuring alongside the COVID-19 
response and other business-as-usual activities. One local stakeholder told 
us that local capacity is being stretched due to the need to consider the 
implications of public health reform alongside the COVID-19 response and 
the recovery of other business activities. Our reports on reorganising bodies 
in government have highlighted the importance of effectively managing both 
transition risks and business-as-usual risks simultaneously, ensuring that 
management focus on one does not divert resource or result in ineffective 
control of the other.32
•	
Ensuring clear accountability and governance during and after the transition. 
Our interim report on NHST&T found it had an unusual organisational 
relationship with the Department, with unclear accountability. NHST&T is 
subject to the Department’s financial, information and staffing controls. 
Until December 2020, its then executive chair reported to the Prime 
Minister and Cabinet Secretary before this changed to the Secretary of 
State for Health. The creation of UKHSA creates an opportunity to clarify 
these arrangements. However, our reports on organisational restructuring 
in government have highlighted the challenges to maintaining clear lines 
of accountability and governance over the budgets of organisations being 
transferred.33 The Department mitigated this risk by making its second 
permanent secretary accountable for NHST&T’s spending until accountability 
transfers to the chief executive of UKHSA on 1 October. However, three 
different accounting officers will have been responsible for UKHSA’s 
spending within the space of five months, bringing risks of confused 
decision‑making and accountability.
•	
The need to determine and establish the base level of capacity that UKHSA 
needs. One of the government’s objectives for establishing UKHSA was to 
“ensure the nation can respond quickly and at greater scale to deal with 
pandemics and future threats”. UKHSA will therefore need a plan for how it 
could scale capacity up and down, including determining the baseline capacity 
it needs to hold for testing, tracing and data systems.
32	 National Audit Office, Short Guide to Reorganising Arm’s Length Bodies, 1 December 2010. Available at: 
www.nao.org.uk/report/short-guide-reorganising-arms-length-bodies-2-2/
33	 See footnote 32.

Test and trace in England – progress update  Part Four  75 
•	
The loss of corporate knowledge, capacity and skills is also a key risk as 
NHST&T recognises that staff may choose not to transition to UKHSA. It is 
heavily reliant on a temporary workforce, with some 99% of its staff having 
fixed end dates.
Securing benefits from laboratory infrastructure
4.17	 A November 2020 business case for the £10 billion expansion of testing in 
2020-21 committed to leaving a lasting ‘legacy’ from NHST&T’s work. It stated that 
the £150 million investment in laboratory infrastructure would provide sustainable 
modern diagnostic capability post-COVID-19, with two major aims:
•	
Diagnostic preparedness for future infectious disease emergencies.
•	
Transformation to provide early diagnostics for cancer, cardiovascular and 
metabolic diseases, thus facilitating early preventative interventions.
•	
The plan also committed to creating new industrial capacity in the UK life 
sciences industry, resulting in significant job creation and economic growth.
4.18	 NHS England and NHS Improvement told us that it was not informed of the 
business plan commitment to use the Test and Trace laboratories for this purpose 
at the time the commitment was made. It has now started to have conversations 
with NHST&T about potential legacy opportunities. NHST&T has identified various 
potential benefits from investment in early diagnostics, including scope to treat 
patients sooner as a result of pre-symptomatic testing. It also told us that there are 
opportunities to develop regional hubs and co-located life sciences clusters, which 
would create jobs and economic growth. However, it does not yet have detailed plans 
for how these benefits can be achieved, despite committing to developing a benefits 
realisation strategy by the end of December 2020 in its November 2020 business 
case. As such, it is unclear what the benefits are, who is delivering them and 
whether there are risks that will need to be managed. The Department will own the 
Leamington Spa laboratory for the next 18 months and Lighthouse labs are owned 
by private and NHS partners. NHST&T told us that detailed planning will be taken 
forward by UKHSA.

76  Appendix One  Test and trace in England – progress update
Appendix One
Our audit approach
1	
This is the report of an audit updating on the test and trace services in England, 
including the ongoing operation of the NHS Test and Trace Service (NHST&T). 
It focuses on the period from November 2020 to April 2021 and follows an interim 
report published in December 2020 that focused on the period from the end of 
May to the end of October 2020. 
2	
This update report reviews:
•	
major changes to the test and trace programme and its operating context since 
October 2020;
•	
performance since the end of October 2020, including a focus on the overall 
effectiveness and impact of the test and trace system;
•	
budgets and spend, including areas of significant Parliamentary interest 
(contracts, consultants, utilisation rates); and
•	
future strategy and plans for NHST&T, including the transition to the UK 
Health Security Agency and plans to secure longer benefits from investment 
in testing infrastructure.
3	
This report is mainly factual in nature. We originally intended to publish a 
fuller value-for-money assessment following the interim report but, following the 
second wave of infections in December 2020, we have decided instead to publish a 
more rapid update report. This report was specifically requested by the Committee 
of Public Accounts and has been undertaken primarily to fulfil the Committee’s 
evidence requirements rather than providing a full assessment of value for money. 
A full assessment of the programme at this time would be also challenging due to 
the ongoing nature of the response, and changes in the test and trace programme.
4	
Our audit approach is summarised in Figure 27 on pages 73 and 74 and our 
evidence base is described in Appendix Two. 

Test and trace in England – progress update  Appendix One  77 
Figure 27
Our audit approach
Test and trace programmes are a core public health measure in epidemics, alongside other actions such as social 
distancing and handwashing, to reduce infections. Through early identification, potentially infectious contacts of infected 
individuals can be traced and encouraged to reduce their interactions with others, thereby reducing disease spread. In 
May 2020, the government launched the NHS Test and Trace Service (NHST&T) in England, with an overall aim to “help 
break chains of COVID-19 transmission and enable people to return to a more normal way of life”.
The objective 
of government
The launch of NHST&T combined testing and tracing into a centralised national programme and built on the central 
delivery model already being developed for testing. NHST&T is responsible for leading development of the test and 
trace provision, which entails working with other national and local bodies, including the Department of Health & Social 
Care, Public Health England and local authorities. Many organisations outside government are also contracted to help 
deliver different aspects of test and trace services.
How this was 
achieved
Major changes to 
the programme and 
its operating context 
since October 2020, 
including the impact 
of rising infections and 
the government’s wider 
response, planning and 
decision-making, aims 
and objectives, local and 
national interfaces.
Finances and main 
areas of spend against 
budget, including area of 
significant Parliamentary 
concern (such as 
contracts, consultants, 
utilisation rates).
Performance since 
October, including against 
key commitments and 
advised thresholds, 
and focusing on the 
effectiveness and impact 
of the test and trace 
system overall.
Future strategies and 
plans for NHST&T, 
including its longer-term 
operating model 
and transition into 
UKHSA, local and 
national interfaces, 
and how longer-term 
benefits will be secured 
from investments in 
testing infrastructure.
Our key areas 
of focus
As part of our fieldwork for this review, we:
• reviewed a range of documents to understand ongoing developments with NHST&T and its plans. This included 
published material and internal documents accessed under our statutory audit rights. This included ministerial 
submissions, business plans and cases, Executive Committee reports, financial and management reports, 
internal and external communications, contract information, and guidance documents;
• analysed data from a range of sources to understand the operational and financial performance of NHST&T. 
This included publicly available data from the Office for National Statistics, internal financial information, and 
regular reporting of key performance indicators and metrics;
• carried out stakeholder interviews to understand external views about the service and its effectiveness, 
including with the Local Government Association, Faculty of Public Health, Early Years Alliance, Universities UK, 
Association of School and College Leaders, National Association of Head Teachers, Road Hauliers Association, 
and British Medical Association. We received documents and reports from some of these stakeholders and 
reviewed relevant documents published online by these and other sources;
• consulted with National Audit Office modelling experts to understand the inputs and assumptions related to 
NHST&T’s model estimating its impact on reducing the R number; and
• reviewed departmental commercial data to understand the number, value and composition of contracts let by 
NHST&T and how it was developing its commercial and contract management approach.
Our evidence

78  Appendix One  Test and trace in England – progress update
Figure 27 continued
Our audit approach
Our conclusions
The primary goal of NHST&T is to help break chains of COVID-19 transmission and enable people to return towards 
a more normal way of life. Since it was established in May 2020 there have been two national lockdowns and more 
than four million confirmed cases. In order to break chains of transmission, SAGE advises that no more than 48 hours 
should elapse between identification of an index case and their contacts self-isolating, and that 80% of these contacts 
would need to be reached. NHST&T now reaches around 90% of all contacts, and has reduced the elapsed time to 
trace contacts for in-person PCR tests. However, in-person PCR tests make up a declining minority of tests, and it is 
less clear whether the wider system is operating as quickly as it needs to. Since November, it has rolled out a national 
asymptomatic testing programme to seek to identify those people who do not know they have COVID-19. Only a 
small minority of the tests it has bought have been registered as used, and NHST&T are now undertaking research to 
understand the reasons for this with a work programme underway to bring about improvements. The success of the test 
and trace programme relies on the public coming forward for tests when they have symptoms, carrying out asymptomatic 
tests when they do not, and complying with instructions to self-isolate where necessary. NHST&T is responsible for 
driving up public compliance, but research suggests that only a minority of people who have COVID-19 symptoms come 
forward for testing. It has no target for increasing this, the uptake of LFD testing or compliance with self-isolation.
NHST&T was set up at speed with a workforce heavily reliant on consultants. It had planned to reduce its dependency on 
consultants but has not yet done so. NHST&T operates in an environment of high uncertainty, where demand for testing 
and tracing can be affected at short notice by new variants, case numbers and policy decisions (for example, national 
lockdowns). It is therefore challenging to forecast costs with precision. However, there is a very wide margin between the 
underspend of around 10% that NHST&T discussed with the Committee of Public Accounts in January 2021, and the 
39% underspend of its 2020-21 budget that it reported two months later. It has taken steps to increase the flexibility 
of its contracts for contact tracing and future laboratory use and has generally improved its provision of data to and 
engagement with local authorities. However, local authorities still struggle to get timely access to the data they need 
to deal with localised outbreaks of COVID-19, and they are unclear on the planned operating model after July 2021. 
To achieve value for money NHST&T must be able to demonstrate both that the interventions it delivers are effective 
in achieving its objective, and that the mix of interventions is the most cost-effective use of public resources.

Test and trace in England – progress update  Appendix Two  79 
Appendix Two
Our evidence base
1	
This update report on test and trace services in England was based on 
evidence collected between February and April 2021. Our approach is outlined 
in Appendix One.
Document review
2	
We reviewed a range of documents to understand ongoing developments with 
the NHS Test and Trace Service (NHST&T) and its plans. This included published 
material and internal documents accessed under our statutory audit rights, 
such as ministerial submissions, business plans and cases, Executive Committee 
papers, financial and management reports, internal and external communications, 
contract information, and guidance documents.
Data analysis
3	
We analysed data from a range of sources to understand the operational and 
financial performance of NHST&T. This included publicly available data from the 
Department of Health & Social Care, NHST&T and Office for National Statistics, 
internal financial information, and internal reporting of key performance indicators 
and metrics.
Audit body interviews
4	
To clarify our understanding of internal documentation and data, we carried out 
a small number of interviews with NHST&T staff. To understand cross‑government 
working with NHST&T, we also spoke to staff at the Office for National Statistics, 
NHS England and NHS Improvement, NHS Digital, the Department for Education, 
HM Treasury, the Cabinet Office and Department for Business, Energy 
& Industrial Strategy.

80  Appendix Two  Test and trace in England – progress update
Stakeholder interviews and documentation
5	
We carried out stakeholder interviews to understand external views about 
the service and its effectiveness, including with the Local Government Association, 
Association of Directors of Public Health, Faculty of Public Health, Early Years 
Alliance, Universities UK, Association of School and College Leaders, National 
Association of Health Teachers, Road Hauliers’ Association, United Kingdom 
Homecare Association, British Medical Association, Independent SAGE 
and the Health Foundation. We received documents and reports from some 
of these stakeholders and reviewed relevant documents published online 
by these and other sources.
Model review
6	
We consulted with NAO modelling experts to understand the inputs and 
assumptions related to NHST&T’s model estimating its impact on reducing the 
R number.
Contract data review
7	
We reviewed departmental commercial data to understand the number, 
value and composition of contracts let by NHST&T and how it was developing 
its commercial and contract management approach.
Limitations of the evidence
8	
Like the interim report, this final report was based on a rapid review of evidence 
drawing predominantly on published information, supplemented by information 
requests to public bodies under our statutory audit powers. We have not audited 
the underlying information systems and source data for completeness or quality. 
However, relevant bodies have reviewed and confirmed the accuracy of information 
relating to them. We reviewed costs and contracts based on internal and unaudited 
management information, but these figures may be subject to change as the UK 
government’s COVID-19 response continues. The analysis and findings in this report 
reflects our best understanding, but there are limitations and uncertainty in the 
completeness and quality of the financial and contractual information available.

CORRECTION SLIP
Title: Test and trace in England – progress update
SESSION 2021-22
HC 295
ISBN: 978-1-78604-377-1
Ordered by the House of Commons to be printed on 23 June 2021
Correction One:
In Part Two of the report there is a page numbering issue which needs to be 
corrected. Part Two starts on page 32 and continues sequentially to page 35 
but after this page the page numbers start again. The page numbering should 
be as follows; 
Part Two should start on page 32 and end on page 47; Part Three should start 
on page 48 and end on page 68; Part Four should start on page 69 and end 
on page 75; Appendix One should start on page 76 and end on page 78; and 
Appendix Two should start on page 79 and end on page 80.
Date of correction: 19 July 2022
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