Matt Hancock needs a ‘big, hairy, audacious goal’ for test and trace

Stanford Business School professors, Jim Collins and Jerry Porras in their book Built to Last: Successful Habits of Visionary Companies, introduced the idea of the ‘big hairy audacious goal’, or BHAG. A BHAG (pronounced ‘bee hag’) is a bold, clear and compelling target for an organisation to strive for, with the appropriate resourcing. A great example was President Kennedy’s speech to Congress in which he said ‘this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to earth’. This audacious goal committed and motivated NASA and its suppliers to deliver a massive step up in performance.

Matt Hancock showed the power of a BHAG with his target of 100,000 Covid tests a day for England by the end of April. Prior to that, the number of tests had shown insufficient growth. The audacious and very public goal, which attracted much scepticism when it was set, energised the NHS and Public Health England, and ended up delivering a fivefold increase in testing capacity (along with some creative counting of postal tests) to meet the target.

It’s now time for Matt Hancock and colleagues to set the mother of all BHAGs, this time for the whole Test, Trace and Isolate programme. As we move away from lockdown and until we are able to deploy a vaccine, our main defence against a resurgence of the disease is Test, Trace and Isolate. It works by finding the close contacts of people who have tested positive for Covid-19, and then isolating them to prevent the virus spreading. England’s Test, Trace and Isolate programme is producing a myriad of data covering aspects of their performance but there is no integrated performance statistic, or clearly articulated target.

That’s why in last week’s Spectator, I launched the first version of a rough but ready single measure of the end-to-end effectiveness of Test, Trace and Isolate. Cheekily, I named this Harding-Hancock Efficiency in honour of Matt Hancock and Dido Harding, but they could clearly find a better name.

I defined Harding-Hancock Efficiency as the proportion of people who are successfully isolated. My initial estimate was that Harding-Hancock Efficiency is at a catastrophic level of less than 5 per cent for England. That means for every person successfully isolated, there are around 20 not isolated, potentially spreading the infection. Clearly this level of performance is not sufficient to prevent a second peak. Hence the need for a BHAG to galvanise the whole Test, Trace and Isolate programme to deliver a step change in performance similar to that achieved in the earlier testing programme. Without this step change, we run a substantial risk of needing to impose the further lockdowns already seen in other countries around the world, if we are to prevent a resurgence of the virus.

So how good does our Test Trace and Isolate programme need to be to prevent a resurgence? Clearly the isolation of any infected person helps a bit, but we need to isolate a critical proportion to stop the growth in the number of infected people. We can do a rough triangulation by using estimates of the R rate. The R rate is defined as the average number of secondary infections produced by a single infected person. If we estimate the R rate for those in isolation and a separate R rate for those missed by Test, Trace and Isolate, we can work out the level of Harding-Hancock Efficiency needed to contain the virus.

We might expect people in isolation to have a lower R rate than the 0.7 we saw for the whole of the UK doing lockdown, as that rate was increased by those in care homes, healthcare workers, delivery drivers, essential retail workers, etc. So maybe we could achieve an R rate of 0.3 for those in isolation. For those not isolated, we also might expect a lower R rate than the 2.7 we saw in the general population before lockdown, as we will be more effectively applying social-distancing, hand washing and wearing masks. If we could achieve an R rate of 1.7 for those not isolating, then we would need to isolate around 50 per cent of those that we would isolate in a perfect world, to achieve an average R rate of 1.0 (the maths is 50 per cent times 0.3 + 50 per cent times 1.7). This means that we would need to achieve a Harding-Hancock Efficiency of 50 per cent. Other assumptions on R rates give a required Harding-Hancock Efficiency of between 40 to 70 per cent.

So that gives a sense of the required BHAG: increasing Harding-Hancock Efficient to 66 per cent by October. Without this level of performance, we run the risk of losing control of the virus as schools reopen and we will need to impose partial or complete lockdowns. Since the start of the Test, Trace and Isolate programme, Harding-Hancock Efficiency has generally improved, but at too slow a pace for this Autumn. So, we are going to need a performance improvement of roughly the same order as the increase in testing after Matt Hancock’s earlier BHAG of 100,000 tests a day.

Achieving this will not be cheap. Next week, I will do a rough sizing of the performance levers needed to achieve a Harding-Hancock Efficiency of 66 per cent. One of which will be changing the incentives for people to isolate by paying them more compensation. And we will also need to do much, much more testing. During the week of 20 to 26 July, we conducted around 260,000 tests a day in England, and found 4,500 newly infected people per week – so roughly 15 per cent of the 29,000 new Covid cases in the same time period, based on the ONS Covid Infection Study. Additional testing is not likely to have the same hit rate as we try to find the asymptomatic, so we may need to conduct well over 2 million tests a day, if we are to find the vast majority of infected individuals – and maybe even a lot more. And these tests will need to be performed faster.

So, achieving the audacious goal will require substantially more funding for Test, Trace and Isolate. But there is good news for Matt Hancock as he approaches the Chancellor for this funding. As a Stanford MBA, Rishi Sunak will probably have been taught by Jim Collins or Jerry Porras, and so will absolutely understand a Big Hairy Audacious Goal, and the required resourcing in successful cases. And that’s great because without the step-up in performance of our Test, Trace and Isolate programme, we run the risk of a second peak and/or the need for further lockdowns and that will end up costing us much, much more.