July 2020

Why is a strategy needed?

It is essential that Wirral has a clearly defined strategy for how we continue to test individuals and our key workers for Covid-19, as well as the most vulnerable groups. It is also essential that we are able to accommodate mass testing which is key to any successful easing of lock down measures and preventing any significant subsequent wave of infection.

Current evolving situation

We anticipate that this testing strategy will be required over at least 2 years, and so we will plan for the long term to ensure adequate capacity. At the same time, this is an evolving strategy in what is a fast-paced situation.

Purpose of a Wirral Testing System

We want a Wirral Testing System that (in the short, medium and long term):

  • Purpose 1: Functions effectively to support the other aspects of Wirral Outbreak Management System by providing information on numbers of cases, location of cases and how these change over time.
  • Purpose 2: Facilitates outbreak control by providing the above in a timely manner by being flexible and timely in access to testing and results
  • Purpose 3: Provides access to testing for the whole population in the right place and at the right time

Prioritisation principles

These are set by the Cheshire and Merseyside Testing Group. The principles which underpin this strategy and will steer our prioritisation are:

  1. We will generally prioritise symptomatic testing over asymptomatic testing.
  2. We will prioritise keeping people safe and saving lives over other considerations – this includes responding to outbreak situations.
  3. We will avoid inflating inequalities across our region through equitable testing / swabbing and mutual aid where required.
  4. We will maximise Pillar 1 utility for higher priority testing and use Pillar 2 as needed.

Purpose 1: Effective Functioning System

We will:

  • ensure the testing system has sufficient flexibility to adapt to changing demands and situations that may arise over the short, medium and long term.
  • have and provide appropriate data in sufficient quantity, in the right format and at the right time in order to support the Wirral Outbreak Management System and demonstrate the efficacy and efficiency of the testing system.
  • ensure that the testing system provides value for money as far as is practicable.
  • provide appropriate and timely communication of advice and information regarding testing, contact tracing and prevention of transmission.

Purpose 2: Facilitates outbreak control by providing support to the Wirral Outbreak Management System

We will:

  • make testing available for those involved in an outbreak in a timely manner and ensure contact tracing is as thorough as possible.
  • ensure that results of tests carried out are available as soon as possible for the Outbreak Management Team.

Purpose 3: Provides access to testing for the whole population in the right place and at the right time

We will:

  • ensure testing is available for all eligible people in Wirral in a convenient place and at an appropriate time
  • ensure that complex settings and vulnerable people are able to access testing and contact tracing assistance when they need it at a place suitable for them
  • provide appropriate and timely advice and information regarding the outbreak to the whole population via a variety of means, ensuring that vulnerable groups receive this in a manner most appropriate to them.

Communications regarding testing

We will:

  • have a Communications Plan for testing that will be comprehensive, timely and adaptable to changing circumstances.
  • ensure that communications regarding testing are effective, efficient and delivered to the right people at the right time via the most effective medium.

Governance

We will ensure the testing system receives effective oversight and scrutiny in order that the Wirral Outbreak Management System has the support it requires.

How do we know when we’ve got there? Measuring success

We will demonstrate if we are achieving the purposes and aims of the testing strategy by using specific indicators that will show how we are progressing.

Where are we now? Current context and situation

Why is a strategy needed?

It is essential that Wirral has a clearly defined strategy for how we continue to test individuals and our key workers for Covid-19, as well as the most vulnerable groups. It is also essential that we are able to accommodate mass testing which is key to any successful easing of lock down measures and preventing any significant subsequent wave of infection.

Links to other documents

Our strategy is aligned with the national strategy and to current national eligibility criteria. . It also contains elements of the Cheshire and Merseyside Testing Strategy which oversees the regional testing system.

It is closely linked to the Wirral Outbreak  Management Plan, in particular its principles of PREVENT, CONTROL and MANAGE. These are outlined in section below.

The COVID 19 Testing System

This is a multi-dimensional system currently involving the NHS, Adult Social Care (ASC), military and workers from other organisations.

Current evolving situation

We anticipate that this testing strategy will be required over at least 2 years, and so we will plan for the long term to ensure adequate capacity.

At the same time, this is an evolving strategy in what is a fast-paced situation. As and when work progresses we expect to add further elements relating to test, track and trace programme, rapid testing options, local swabbing centres, antibody testing, outbreak testing and surveillance testing and other national developments that have benefits for Wirral. Consideration will therefore be given to the short term, medium term and long term aspects of this service.

Government information

The Government will present Local Authorities and Public Health Directors with a clear view of the various testing capabilities that will come under their control at, with some examples showing how they could be deployed to test hard-to-reach and vulnerable people.

Local Authorities and Public Health Directors will request the testing capabilities they think they will need, and give details on how flexible they want them to be, based on their understanding of the testing capabilities and their region’s populations and communities. Wirral wants to implement more local testing as soon as possible, in order to be more responsive to our communities needs.

Therefore this strategy will outline the initial requirements for the testing system in Wirral in anticipation of the government’s announcement, with interim measures. It will be reviewed when the Government advice is published.

Current gaps in provision

A stocktake was undertaken to find issues and gaps in the current testing system. The main current problems are:

  • more flexible adaptable model of testing required to accommodate increased frequency of  testing and possible outbreaks. This would include identifying methods for local testing to  ensure a swift response that is accessible to the entire population
  • assessing local and regional contact tracing and infection control capability in complex  settings and the need for mutual aid (e.g. identifying specific local complex communities of  interest and settings, developing assumptions to estimate demand, developing options to  scale capacity if needed).
  • need for an Outreach Model as some priority groups have difficulty accessing testing, and also  may need support in self isolating.
  • the service needs to be future-proofed against further changes and expansion, for example  timescales of rollout for Pillar 3.
  • staffing and funding- staff used now may be pulled back into their usual jobs as initial  funding may stop.
  • access to data in order to inform the solutions to the problems identified above.
  • ensuring that all outbreaks are promptly reported to the Community IPC Team.

Where do we want to be? Purpose and aims

This strategy is guided by the Wirral Outbreak Plan principles of Prevent, Control and Manage as well as its particular requirements. There are also the 6 enabling factors underpinning this system: NHS Test and Trace, Testing Pillars, Governance, Surveillance, Communications and Workforce. This strategy covers the enablers of NHS Test and Trace and Testing Pillars whilst factoring in the other enablers as appropriate.

Purpose of Wirral Testing System

We want a Wirral Testing System that (in the short, medium and long term):

  • Purpose 1: Functions effectively to support the other aspects of Wirral Outbreak Management System by providing information on numbers of cases, location of cases and how these change over time.
  • Purpose 2: Facilitates outbreak control by providing the above in a timely manner by being flexible and timely in access to testing and results
  • Purpose 3: Provides access to testing for the whole population in the right place and at the right time

Overarching principles and aims

These mirror the objectives of the Cheshire and Merseyside COVID 19 Testing and Swabbing Strategy. Our primary objective is to minimise the overall harm caused by the Covid-19 pandemic and to allow lockdown restrictions to be eased. This includes:

Short Term: Minimising the number of people that come to harm through contracting Covid-19

  • mitigating the risk of future peaks of Covid-19 cases as lockdown measures are eased.
  • ensuring that the most vulnerable people in society are shielded from Covid-19 once lockdown measures are eased.
  • minimising the risk for vulnerable patients of hospital-acquired infection or having potent therapies whilst carrying the virus.

Medium Term: Minimising the number of people that come to harm due to non-Covid-19 conditions because of the impact of the pandemic on the health and care system

  • Allowing wider health and care activity to resume, increasing the number of individuals without Covid-19 treated for both mental and physical health conditions, including elective procedures.

Long Term: Minimising the wider social harm caused by the pandemic (e.g. the impact on the economy, living standards, inequalities etc.)

  • Minimising short-term harm as a result of lockdown measures (e.g. domestic violence, mental health conditions)
  • Allowing people to return to work and education, minimising longer-term harm and the economic impact of lockdown measures

How will we get there? Method of implementation

Pillars of Testing

This strategy refers to Pillars of Testing. The main ones are:

  • Pillar 1 NHS rapid / near patient testing for the most urgent cases (<4 hours turnaround time, but very limited numbers) PCR (swab) testing in local NHS / PHE labs (<24 hours turnaround time)
  • Pillar 2 Commercial testing in national mega labs (SLA 72-hour turnaround time, with Government commitments to improve to 24 hours.
  • Pillar 3 Antibody testing to help understand the proportion of the population who have been infected. Antibody testing has no current clinical indication and does not infer ‘immunity’ from future infection, so we have not included priorities for Pillar 3.

Prioritisation principles

These are set by the Cheshire and Merseyside Testing Group. The principles which underpin this strategy and will steer our prioritisation. We will:

  1. generally prioritise symptomatic testing over asymptomatic testing. See section
  2. prioritise keeping people safe and saving lives over other considerations – this includes responding to outbreak situations.
  3. avoid inflating inequalities across our region through equitable testing / swabbing and mutual aid where required.
  4. maximise Pillar 1 utility for higher priority testing and use Pillar 2 as needed.

Please note, Wirral does not have control or influence over all aspects of COVID 19 testing, but for those that we have we will make sure we maximise efficacy and efficiency for Wirral residents.

Prioritisation of Testing

Testing must be prioritised as we expect the demand for testing will far exceed the confirmed capacity that is available to us.

Priority for mode of testing

This is also set by the Cheshire and Merseyside Testing Group.

  1. Rapid and available near patient testing for the most urgent cases, which may include transfers to vulnerable settings, emergency admissions, outbreak investigations.
  2. Pillar 1 testing at NHS Labs for cases where a sub 24-hour turnaround time is important. 
  3. Pillar 1 testing at PHE Labs for Outbreak related cases where a sub 24-hour turnaround time is important. 
  4. Pillar 2 capacity via supported and supervised swabbing centres where while we would prefer sub 24 hour, we are prepared to use the capacity even if TAT is longer. 
  5. Pillar 2 unsupervised and home testing where unsupervised poor swabbing technique may increase risk of false negative results. 

Priority groups for testing

Again set by the Cheshire and Merseyside Testing Group.

  1. NHS Patients, Care Home residents, Vulnerable  cohorts who are symptomatic.
  2. Symptomatic NHS and Social Care Staff, and /or their symptomatic household members.
  3. All those being admitted to a Hospital or Residential setting with vulnerable residents even if asymptomatic.
  4. All those in vulnerable settings in an Outbreak situation, and those affected under local Outbreak arrangements.
  5. Key symptomatic workers in Schools, Emergency Services & other essential services.
  6. Anyone else who is symptomatic
  7. Routine testing of the most vulnerable hospital patients and care home residents even if asymptomatic as a preventative measure to reduce risk of outbreaks.
  8. Routine testing of front-line health & social care workers, and other agreed essential key workers, even if asymptomatic as a preventative measure.
  9. Individuals identified through TTCE who may be at risk having been in contact with a known COVID-19 positive case, even if asymptomatic.
  10. Anyone else not listed above.

It is worth noting that as Wirral in the Cheshire and Merseyside region we are not currently empowered to fully implement our prioritisation as national test booking routes, including the self-referral portal, are used to allocate much of the Pillar 2 testing appointments at present.

Wirral also does not have direct influence or control over the NHS Test and Trace System and the Regional Testing Sites. This should be bourne in mind regarding our 3 strategy purposes, although we can bring some influence on those who do control these aspects of the system.

Hospital transfers to vulnerable settings

We will ensure that all individuals who are transferred into vulnerable settings such as care homes are tested for COVID 19 prior to transfer, whether symptomatic or asymptomatic.

Antibody testing (Pillar 3)

Antibody (AB) testing is currently undertaken to help understand the proportion of the population who have been infected. Antibody testing has no current clinical indication and does not infer ‘immunity’ from future infection.

Testing that is taking place in the NHS is for surveillance purposes to understand the virus better rather than diagnostic use as the virus is not understood enough to be clear about who does/does not develop antibodies and for how long. The Wirral Scientific and Technical Advisory Cell (STAC) conducted a study of the current evidence base for antibody testing.

Therefore, our strategy for the present time for antibody testing is that we will advocate this testing for surveillance and research where there is clear evidence of potential benefit.

As volumes become available, we will further refine and update our Testing Strategy to include more eligible cohorts for antibody testing if the evidence base for this is sufficient. If and when the utility of these tests includes predictor of immunity, we will consider a shift in priorities to reflect this.

Frequency of testing

Health and care frontline workers

Due to the nature of their work, there is a need to test asymptomatic health and care frontline workers more frequently to avoid more cases. The latest scientific advice will be followed to ascertain how frequently this should be and will be incorporated into the effective functioning system in Section 3.3.

Mass testing of care homes

The Government have offered Care Homes for over 65s and under 65s mass testing. There is also a need for testing of a mutual aid personnel who will be utilised in an outbreak situation when staff may be off ill or self isolating.

We will examine the latest scientific evidence and national guidance for frequent testing and timing of testing to inform our policy.

Mass asymptomatic testing

We will follow the principles stated by the Chief Medical Officer which are:

Asymptomatic testing may only be used where: 

  • the objective is to increase understanding about the spread of the virus – for example studies to establish prevalence within a given area, setting or group;
  • a new population is being introduced into a high-risk, closed setting; 
  • where there is a strong reason to believe that prevalence may be higher than it is in the general population; and/or
  • to manage an outbreak (to mitigate spread of infection).

Purpose 1: Effective Functioning System

We will:

  • ensure the testing system has sufficient flexibility to adapt to changing demands and situations that may arise over the short, medium and long term.
  • have and provide appropriate data in sufficient quantity, in the right format and at the right time in order to support the Wirral Outbreak Management System and demonstrate the efficacy and efficiency of the testing system.
  • ensure that the testing system provides value for money as far as is practicable.
  • provide appropriate and timely communication of advice and information regarding testing, contact tracing and prevention of transmission.

Purpose 2: Facilitates outbreak control by providing support to the Wirral Outbreak Management System

We will:

  • Make testing available for those involved in an outbreak in a timely manner and ensure contact tracing is as thorough as possible.
  • Ensure that results of tests carried out are available as soon as possible for the Outbreak Management Team.

Please see Wirral Outbreak Plan for more detail on the Wirral Outbreak Management System for handling complex cases and Outbreaks.

Purpose 3: Provides access to testing for the whole population in the right place and at the right time

We will:

  • Ensure testing is available for all eligible people in Wirral in a convenient place and at an appropriate time
  • Ensure that complex settings and vulnerable people are able to access testing and contact tracing assistance when they need it at a place suitable for them
  • Provide appropriate and timely advice and information regarding the outbreak to the whole population via a variety of means, ensuring that vulnerable groups receive this in a manner most appropriate to them.

Communications regarding testing

Communications Plan

The Communications Plan for testing will be comprehensive, timely and adaptable to changing circumstances.

We will ensure that communications regarding testing are effective, efficient and delivered to the right people at the right time via the most effective medium.

Communications network for professionals

We will ensure that there is an effectively functioning communications network for professionals with regards to testing to enable issues, information and advice to be shared.

Governance

Scrutiny Boards

Scrutiny for testing is currently provided by:

  • Outbreak Control Operational Group
  • Outbreak Control Strategic Group
  • Cheshire and Merseyside Testing Group

Provides regional overview and steerage around the Cheshire and Merseyside Testing System.

  • Wirral Scientific and Technical Advisory Cell (STAC)
  • Reporting around contracts- Clinical Service Specs
  • Quality meeting with Community Trusts

The Local Outbreak Engagement Board and Health Protection Boards are being developed. Please see the Wirral Outbreak Plan for proposed functions of these Boards.

We will ensure the testing system receives effective oversight and scrutiny in order that the Wirral Outbreak Management System has the support it requires.

Budget and expenditure

Needs and requests for funding regarding the Testing System will be assessed by the Outbreak Operational Support Group. Once assessed as beneficial and cost effective, they will be considered and signed off by the Outbreak Strategic Control cell and the Local Outbreak Engagement Board. This will be funded from the COVID 19 Grant for the first 2 years.

How do we know when we’ve got there? Measuring success

We will demonstrate if we are achieving the purposes and aims of the testing strategy by using specific indicators that will show how we are progressing.

Aims and purposes: of:

Wirral Infection Management System Wirral Testing Strategy
1. Sustained decrease in infection rates Purpose 1: Functions effectively to support the other aspects of Wirral Outbreak Management System by providing information on numbers of cases, location of cases and how these change over time.
2. Sustained reduction in the risk of transmission Purpose 2: Facilitates outbreak control by providing the above in a timely manner by being flexible and timely in access to testing and results
3. Ensure vulnerable people are protected in community settings Purpose 3: Provides access to testing for the whole population in the right place and at the right time
Aspect Indicator Source of Data
Prevent Number of cases/community NHS Test and Trace
  Number of outbreaks PHE
  Cases in priority groups NHS Test and Trace and PHE
Control Contactable cases by NHS Test and Trace NHS Test and Trace
  Percentage of key workers swabbed by Community Swabbing Team within 24 hours CCG
Manage All appropriate cases or suspended cases in an outbreak swabbed within 24 hours Community Swabbing Team