Bulletin July 2020 Number 191

These three articles from the College Regional Councils in Scotland, Wales and Northern Ireland describe the different approaches and their particular challenges around the introduction of testing during the pandemic.

Northern Ireland: our response to COVID-19

The Northern Ireland response to the COVID-19 pandemic has in some way been different from the rest of the UK. This is in part due to geography, with reduced travel between Great Britain and the island of Ireland. Reduced travel arose not only from people being placed into lockdown, but also by the collapse of air travel precipitated by Flybe entering administration; 90% of flights from Belfast City airport were run by Flybe.

Perhaps on a more positive note, there was a unified approach to managing the pandemic by the Stormont Assembly, with all sides of the political spectrum appearing to work together while trying to balance the advice and guidance from the UK and Irish governments for the benefit of the Northern Ireland population.

The preparation for the surge was based, similar to the other countries in the UK, around three areas: creating capacity and expanding critical care; supporting staff and increasing availability; and reducing routine work. Interestingly, guidance on these areas, issued by the Department of Health, did not mention the role of pathology in the testing plans or the need for an integrated approach. Increased capacity for testing in Northern Ireland has been mainly through the existing virology laboratories or via the development of a regional facility based at AFBI (Agri-Food and Biosciences Institute), in partnership with staff and equipment from Queen’s University Belfast and Ulster University, with the first test processed in mid-May. This is despite the biotech firm Randox being based in Northern Ireland and supplying tests for the drive-through testing sites in Northern Ireland.

By the end of May, 523 deaths had occurred in Northern Ireland with approximately 68,000 tests completed. Recent calls have been made to increase the number of daily tests for COVID-19 by around 1,000 to enable cancer services to get back on track, particularly in the pathology departments that will be dealing with the backlog of active and undiagnosed cancers. While the role of pathologists in the current situation has not been fully recognised, they have dealt with the challenges in a professional and efficient manner.

This article was finalised on 11 June 2020.

Professor Ken Mills – Chair, Northern Ireland Regional Council

SARS-CoV-2: a Scottish perspective

Laboratory medicine provides safe and timely data on which 21st century medicine is based. Testing for SARS-CoV-2, its delivery and controversies have demonstrated this point. Future safe management of the outbreak is crucial to the health and safety of the population at home, at work and in health-care. People are scared of the unknown and the language of war that has been prevalent throughout the pandemic may have helped embed fear. Encouraging people to re-engage with healthcare in primary, secondary and social care will require demonstration that environments are safe for them to do so. A system for testing, tracking and tracing that has the confidence of the population as well as healthcare providers is an important part of this. The relevance of pathology specialties and virologists in this context is manifest. Governments are perceived to favour advice from industrialists and entrepreneurs about COVID-19. There is a need for balance that involves credible, experienced NHS laboratory medicine and science staff at the heart of the testing strategy and delivery. Standards in laboratories are not annoying nit-picking – they and the registered staff who deliver laboratory care in accredited settings are the assurance of safety the public needs.

Strategic approach in Scotland

Scotland has developed a clinical governance frame-work with SARS-Cov-2 testing as the remit. Three associated groups have responsibility for strategy, delivery and quality. These groups are chaired by senior NHS laboratory medical and scientific professionals. They work collaboratively with Scottish government officials. The testing system in Scotland is based on a distributed service model where local NHS Board departments work across a supportive network of equals, each knowing what the other is doing, to share intelligence, expertise and workload. This includes the diversity of scale across Scotland’s geography from small Boards, like NHS Western Isles, to the largest, NHS Greater Glasgow and Clyde. There has been cooperation between university laboratories across Scotland and a so-called light-house laboratory in Glasgow. Alignment of these with NHS standards has been and remains a priority to ensure that a result in one laboratory would be the same from another. This provides accurate and consistent data with which to ensure safe understanding and decisions as the pandemic evolves.

Looking ahead, capacity building is important as we move from seeking the organism to measuring people’s immunological response to it. An important consideration is having space for staff as well as the equipment required. Distancing effectively reduces the space in a building and so the pressure on facilities increases. Many laboratories were built before the expansion of clinical demand for pathology services and were physically too small prior to the current crisis. While this is true for many clinical areas across all care sectors, we need to ensure that laboratories and mortuaries are not forgotten in developing safe environments for patients and staff. Space includes room for staff to relax and rest, socialise safely and foster a supportive educational culture in which to work.

Operational features

Several lessons arise from COVID-19 in Scotland. Clinical leadership is among those. We have seen a lot of the ‘command and control’ style of management in this crisis. There is value in facilitating ‘ground-up’ involvement in future-proofing services while reinforcing this within and from senior management. Literature supports the success of consensual management style and investment in staff in public sector organisations.

Linking the COVID-19 experience to education is vital. For us pathologists, expanding the drive for public engagement should be extended to include our colleagues in other medical disciplines whose understanding might be described as rudimentary. There is a clear need to focus non-clinical managers in the NHS and politicians on the integral nature of laboratories to modern healthcare. This is as true in Scotland as elsewhere. Investment in staff development and thinking about joined-up services – nationally coordinated, locally delivered – are helpful spin-offs. Educational programmes for doctors, and clinical and biomedical scientists urgently need to be reinvigorated. This requires investment from Health Boards and flexible and effective facilitation by the Deanery. The College has been quick and effective in developing guidance.

In Scotland, virology colleagues have overseen a major effort, moving from a position of little resource to one where capacity is ahead of demand. The establishment of management and delivery groups and university collaborations are aligned with the Scottish National Laboratory Programme’s tenet, ‘right test, right time, right place’, ensuring results are recorded in correct, accessible patient records.

Communication within and around the system remains vital to success: ensuring people are valued, and there is shared understanding and collaborative intent towards agreed objectives. There is a need for investment to maintain capacity that will be adequate for now and flexible for future. This requires ongoing commitment from government, its offices, Health Boards, and pathologists.

This article was finalised on 23 June 2020.

Professor Peter Johnston – Chair, Scotland Regional Council

COVID-19: the Welsh response

One of the problems in dealing with a widespread infection, particularly one we haven’t seen before, is the early recognition of symptoms and likely spread. By the time SARS-CoV-2 was documented in the UK, two clear observations could be made. First, it must have been here before it was identified and there are data from Oxford supporting this. Second, the UK stood to benefit from experience in other countries, particularly the experience in South Korea, Italy and Spain. Instead, we delayed starting the age-old treatment for epidemic management – test, trace and protect. I will leave it to other people to comment on the initial UK response generally and, of course, it is easy to criticise in retrospect.

Initial approach to testing in Wales

It is interesting to observe the different approaches the four countries of the UK took to the testing of their populations. In this, Wales had two significant advantages over England. First, our index cases were defined later than in England, with the picture in the UK largely spreading from East to West and from South to North (aside from a Real Madrid-induced pocket in Liverpool). This means that we entered lockdown earlier in the course of the pandemic and the spread of infection may have been more contained, although we had large outbreaks in Gwent and North Wales. Second, testing for healthcare personnel and other key workers began earlier and made a huge difference to the number of people able to make an early return to work. A negative test result = back to work. This was good for health-care planning and provision, as well as for personal well-being and confidence: it is quite a relief to be declared negative for an unknown and potentially fatal disorder. The Welsh government definitely got this right and we were way ahead of England on testing for many weeks.

Reliability of samples

There remain concerns around testing. If symptomatic workers screen negative, what condition do they really have? And is that OK to take to work? There was little support for this. Concerns exist about the reliability of samples – a single dry throat swab in Wales, rather than two wet swabs in England. Does that affect sample quality? And what about the lack of a tongue depressor? If you can’t see what you are swabbing, it is unlikely to be good quality. I didn’t even gag when I was swabbed. I don’t think it went far enough. I was negative. It speaks volumes for the standardisation of sample procurement and laboratory testing. SOPs and accreditation standards exist to ensure tests are done properly and the results are reliable. The use of unaccredited commercial laboratories to increase testing capacity is a political and unscientific manoeuvre that pathologists should resist.

Contact tracing

As far as I know, little or no tracing of contacts was done in the early days. Now that we seem to be over the worst of the (first?) peak, we are invoking a large-scale public screening test programme with tracing of contacts. The public remain the key partner in this programme – if I have only mild symptoms, I might need some incentive to find a drive-through centre or order a home test kit. If I have moderate or severe symptoms, I might not be able to do either. Furthermore, can I really remember everyone I had a contact with over the last seven days? What counts as a contact? Healthcare workers will necessarily be in contact with definite or suspect cases almost daily. We then take it with us when we discuss a case with a colleague, or we go home and potentially take it with us. We need a definition of contact that does not mean that half the healthcare workforce is in isolation after being in contact with a patient, or a colleague who has.

At the time of writing we are expecting an antibody test to be widely available within a few weeks and, by the time you read this, you may have been tested. This is a crucial step forward as we can start to map the demography of who has been exposed. It will be particularly useful for healthcare workers as we attempt to return things to normal and recover our surgical programmes and cancer treatment.

Other impacts of the pandemic

It is interesting to note that nearly all histopathology departments have reported an 80% decrease in their activity, while virology and microbiology departments have had to completely rethink how they provide their service, and clinical disciplines have been contributing to covering COVID wards. We have lost our core medical trainees somewhere along the way and specialist registrars have had their training interrupted and their exams postponed, adding to the immense stress this clinical situation has caused. Wales has made significant contribution to COVID studies and Angharad Davies, Health and Care Research Wales’ Specialty Lead for Infection, points to the huge efforts of colleagues across Wales in recruiting to UK national trials. Wales hit the ground running and at the end of March, Welsh Health Boards were the top recruiters in the UK to the RECOVERY trial and have led on the initiation of convalescent plasma studies. To date, Wales has recruited over 2,000 patients to more than 30 COVID studies.

Of course, all this disruption demands that we rethink the way we run our labs, how we deliver our services and how we educate (and examine) our trainees. I hope we will be able to look back at these trying times as the birth pains of an improved preventative, diagnostic, therapeutic and teaching National Health Service.

This article was finalised on 11 June 2020.

Dr Jonathan Kell – Chair, Wales Regional Council