Section Four – How We Test
Scotland's infrastructure for testing for COVID-19 has developed considerably since the beginning of the pandemic. This infrastructure includes an expansion of where and how people can have the test conducted ('swabbing'); where, and how rapidly, the tests are processed in laboratories; and, critically, how the results of tests are linked to our data infrastructure and the patient record to support appropriate action at an individual, community and population level.
Both quality and speed are critical elements of each stage of the PCR testing process.
There are six Regional Testing Centres in operation where swabbing takes place (Glasgow, Aberdeen, Edinburgh, Dundee, Prestwick and Inverness) and eighteen Mobile Testing Units located in different parts of the country. In addition, home testing kits are available – usually for self-administering, though all Health Boards have arrangements in place to support those who might find completing a home test challenging – for example through home visits from the community nursing team. Many NHS Boards have also established local testing arrangements, including mobile testing teams, and these will continue to be developed and sustained as an important part of making tests as widely available as possible.
The Scottish Ambulance Service will take over responsibility for the operation of mobile testing units in Scotland from the beginning of September 2020.
Mobile units will be deployed to support a comprehensive approach to managing outbreaks. The Scottish Ambulance Service role in overseeing mobile testing units is part of the strategy of creating the long term sustainable capacity in Scotland to manage the pandemic, building on our services where they have extensive existing knowledge and experience of the geography in Scotland and ensuring testing capacity exists in all areas – including remote and rural areas.
While much of the attention in testing is focussed on sampling and processing and our capacity to increase these as part of our winter preparation; equally important is that all groups in our communities can easily both book a test and access a test when required.
We know there are potential barriers for some – for example, the regional test centres, and often the mobile units, require access to a car.
We know too that the best way to understand these barriers is to speak to people in our communities, in line with our overall principle from the Framework for Decision Making to engage with the people of Scotland as the pandemic progresses. We are engaging with the public as we continue to design our testing services and continuously improve their accessibility and usability by different groups.
Our Test and Protect engagement work is using feedback from people who have been through the test processes in Scotland to make improvements. We have also launched a Dialogue public engagement exercise to better understand barriers to access tests by directly engaging with the public in Scotland.
And our Health Boards play a critical role here. All Health Boards have established patient transport systems, to provide support to those without access to transport.
Sampling and Laboratory developments
Since the beginning of the pandemic, there has been significant development and expansion of both the sampling (swab-taking) and the laboratory infrastructure and capacity in Scotland.
Access to sampling (swab taking) has grown rapidly and there are now a number of established channels available which enable clear pathways for accessing testing to be defined and shared publicly. Sampling channels include Regional Test Centres, Mobile Test Units, NHS hospitals and community centres, Care Homes, home testing, Satellite Hubs, and imminently Walk Through sites. Laboratory capacity to process swabs has also grown rapidly, and is now in the region of 35,000 tests per day.
Further demands on this capacity in the immediate future will come from an anticipated rise in people with COVID-like symptoms over the winter months; testing all close contacts of index cases; testing in the context of outbreaks; and testing to support both direct patient care and mitigate against the risk of hospital based transmission as the NHS remobilises. Our surveillance testing programmes will also require capacity around both PCR test processing and antibody test processing.
We know with winter coming that we will need to continue to build this capacity and its sustainability. We intend, working with the UKG programme, to continue to build sampling pathways, and to build laboratory processing capacity to approximately 65,000 tests per day between NHS Scotland laboratories and the Lighthouse Lab in Glasgow.
The Lighthouse Laboratory in Glasgow is a crucial component to enabling increased testing in Scotland. We have an agreement with the UK Government that the Glasgow Lighthouse Laboratory will operate on a Scotland first approach, up to the level of 40,000 tests per day. Ongoing liaison with the University of Glasgow ensures an integrated approach to the service across Scotland, both in terms of quality and performance of service delivery. These developments are augmenting the existing core strengths in the NHS Scotland Laboratory network, which has been, and will continue to be, critical in our response to the pandemic. This includes individual NHS Scotland laboratories and their workforces in territorial health boards, and national groups including the National Laboratories Programme and the Scottish Microbiology and Virology Network.
We also plan to build resilience and sustainability in our NHS Scotland laboratory capacity on a regional basis. In a proposal delivered in partnership with our clinical and scientific community, we will invest in new equipment on a regional basis, providing additional capacity for a further 10,000 tests a day. This will ensure that microbiology and virology laboratories have the ability to deliver responsive business as usual testing, and provide resilience and support with the anticipated increased demand as winter pressures drive up the need for COVID-19 testing to differentiate between respiratory infections and COVID-19.
Being ready to adapt
The testing priorities of the next three months to November may be different to the following three months to January 2021, and to the period beyond that. Our priority in the next phase is using testing as part of our overall strategy of continuing to drive down cases to as low a level as possible, so that schools can reopen, universities and colleges return, and as close to a new normal can be experienced by our communities.
We know in the winter the challenges may increase. We know this virus transmits more easily indoors, and that people will be spending more time indoors in winter. We know there are risks of other illnesses, including seasonal flu, occurring at the same time as potential increase in COVID transmission.
We can see now the likelihood for the demand for testing to grow, testing that will be critical in order to genuinely distinguish COVID from other illnesses. It is not inconceivable for the numbers of people with symptoms compatible with COVID, who will require testing, to be in the tens of thousands per day in winter in Scotland.
This means one of our core principles of our strategy - that our approach to testing, including prioritisation, is flexible and adaptable to the prevailing conditions of the pandemic at any time – will require genuine translation into action. It means there may be groups we test now that we will not test in winter, or that prioritisation for testing in winter is considered to protect those most at risk of most harm.
These decisions may not always be easy. They will require being well informed by those with expertise in every aspect of an effective testing system that makes maximum contribution to minimising harm – from the scientific, clinical, public health communities, virology and microbiology, operational, logistics and delivery expertise, modelling and scenario planning capabilities, and a clear understanding of ethics, acceptability and the impact of any changes to testing eligibility on the whole system.
Being ready to adapt also means being ready to take advantage of innovations in testing should they become available. Looking ahead, we expect to see developments in testing capability, which could bring about significant changes in our approach to testing by making sample collection more straightforward, and turnaround times quicker.
For example, if testing of saliva samples is found to be sufficiently accurate to be a suitable alternative to current nose and throat swabs, and if a robust supply chain is in place, this could be used to make sample collection more straightforward. This could mean that even more people could self-sample, rather than requiring a sample to be taken by a trained member of staff, and it would avoid the discomfort that some experience when a swab is taken.
Progress is also being made with the development of rapid point of care or near point of care testing, which would enable rapid results to be provided, with testing potentially undertaken outwith laboratory settings. While it is unlikely that these types of tests would replace the gold standard laboratory PCR tests, they could have a significant role by providing results in less than an hour.