“The message from the World Health Organisation has been clear for weeks – test test test,” says Dr Alex Armitage. “It’s welcome that the Health Secretary now seems to be taking this seriously, but it’s taken a very long time to get here – and there are still logistical issues we are very concerned about”.
Dr Armitage is an A&E paediatrician based in London, and part of a group of frontline medical staff who are raising questions about the ways in which the increased testing for COVID-19 is being planned in Britain – and proposing some potentially radical solutions.
The problems are clear. So far, the UK has tested roughly 150,000 people in total for the coronavirus – new commitments to get this to 100,000 a day will require a massive effort from both government and the health service. Measures like self-isolation and social distancing are the key to slowing the spread of infection, and key to defeating the virus.
But effective testing will become ever more essential for data gathering in the medium-long term, as the acute crisis hopefully passes and the country needs a system to determine who might be able to re-join the workforce.
What particularly alarms Dr Armitage and his colleagues though, is the dangers the current testing regime presents to the health service itself. There has been widespread anger over the fact that, as recently as 1 April, only 2,000 NHS workers had received tests, out of a total of 500,000.
The government has promised to dramatically ramp this up. But what concerns Dr Armitage is not just the number of tests being carried out, – but how, when, where, and by whom they are performed.
“It has been reported that a quarter of NHS doctors are now self-isolating and unable to work,” he explains, “that’s exactly what we were seeing – about one in four essential staff off sick or having to shield themselves, which is a terrifying reduction in capacity when facing a pandemic. So, a few of us put our heads together and tried to come up with a better system.”
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A few initiatives around drive-through testing and “community hubs” aside, the UK’s COVID-19 testing system essentially works like this: if a patient develops symptoms, they phone their GP or 111. If deemed appropriate, they will be referred to a hospital for testing. The problem was, as Dr Armitage and his colleagues saw it, not only that people were breaking isolation in order to receive tests, but that doctors and health workers were getting exposed and becoming ill while testing and treating them.
In the end, the flash of inspiration for their team’s proposed new system didn’t come amid flip charts and data sheets at the hospital. Dr Armitage explains: “a medical colleague was on some downtime, after several long shifts. He was watching the movie Ghostbusters with his young son and had the lightbulb, eureka moment. We then fleshed the idea out over several days with colleagues across the country.”
The new system that the team proposes would work roughly like this: if a patient exhibits symptoms, they call their GP or 111, who can refer them, if appropriate, to a mobile COVID-19 Assessment and Testing Team (CATT), which will come to their home to perform the testing.
They envision the CATT units as teams of three, with one car and full Personal Protective Equipment, working in rotation, with centralised administrative support organised through local health authorities.
The CATT teams, who could be made up of health workers or even volunteers with special training, would perform the necessary testing at people’s homes. No patient is forced to break isolation or social distancing. If the tests come back negative, the patient may be able to be discharged back to the care of their GP for further monitoring.
If the patient does test positive for COVID-19, however, they can be admitted to a “Virtual Ward”. They stay shielded in isolation in their home – but are given a very specific set of instructions to monitor their symptoms. They relay these measurements to a central database via text or phone. A specialist monitors this data, checking in as required – probably twice a day, as if doing rounds on a physical ward. Based on this monitoring, should the patient’s health decline, they can immediately be brought into hospital.
Dr Armitage explains the potential benefits this system of testing might offer: “First off, it keeps doctors and essential health workers out of harm’s way. It allows people to receive testing without endangering themselves or others.”
“And, importantly, the visible presence of these teams engaging with people where they actually live could do wonders for people’s trust in the entire medical infrastructure and willingness to follow guidance – which we have sometimes seen wavering in the face of this pandemic.”
The team sees these proposals as a step forward from both “community testing hubs”, which still require people to break isolation, and drive-through testing, which also de-prioritises those without access to their own car.
The most crucial part of this proposal is perhaps the assessment and monitoring phases – the Virtual Wards. “Virtual Wards would enable patients to have some assurance about the progress of their care, while maintaining isolation and social distancing,” he insists.
“The telehealth and data processing solutions to make these Virtual Wards possible already exists, and could be streamlined and scaled up. Possibly the private sector could be engaged to accelerate this effort.”
As a side benefit, Dr Armitage also points out that the “Ghostbusters” model has seemed to resonate with people his colleagues have spoken to. The image of mobile units, proactively going out among the population – then being able to be monitor patients without the sometimes alarming prospect of a hospital visit, has apparently met with positive responses.
“This model could be presented in a way that is commonly understood by the majority of the population, drawing on themes of camaraderie and positivity during a time of nation-wide crisis.”
“The crisis we are facing is coming on fast. If any part of this proposal can help medical systems cope, or inspire other creative solutions, it shall not have been wasted effort.”