To solitude: Learning from other countries on how to improve compliance with self-isolation

Despite the hope offered by the start of the biggest vaccination campaign in NHS history, we are still some distance from community immunity and cannot lose sight of the need to control transmission. Every death now feels even more tragically avoidable as multiple effective vaccines are rolled out.  

Isolating cases has always been critical, but that’s now especially true given a more contagious variant of the virus that appears to have contributed to a surge in cases in the UK. Even with another national lockdown underway, effective testing, tracing and isolation strategies remain essential.

But so far NHS Test and Trace has been beset with problems. The current system is ‘leaky’, and even six months after its introduction was still missing an estimated two-thirds of exposed contacts. The government has invested in more rapid testing and improved contact tracing to right some of these wrongs, bringing the total price tag of the programme to a staggering £22 billion for 2020/21.

To actually reduce transmission the programme needs to change behaviours, and help people to self-isolate once they test positive or have been in contact with someone who has. While the number of people who follow self-isolation rules is not consistently measured, data suggests that adherence is low.

Surveys between March and August 2020 found that only 11% of people in the UK notified of being in recent close contact with a confirmed case didn’t leave their home. For context, SAGE suggests that 80% of contacts of an index case would need to isolate to control spread. The government spending watchdog recently warned that such high levels of non-compliance threaten the viability of the NHS Test and Trace programme. 

So what policy choices do we have to improve compliance? Here we look internationally – as far as can be readily ascertained – to set out five policy options as we enter the next stages of the pandemic. These options are not mutually exclusive, and for each we set out the scope for change and key considerations for implementation.

Given that self-isolating is a struggle for many due to their work, caring responsibilities or broader life circumstances, we conclude with a discussion of how different approaches might impact inequalities. A table at the end summarises the approaches taken in a selection of high-income countries of the OECD, and how the UK compares.

1. Increased income support

Research suggests that economic necessity and being unable to miss work are key factors in why people don’t self-isolate, which is more likely to affect people from lower socio-economic backgrounds who work in essential, public-facing jobs. To self-isolate, many workers will have to take the period as sickness absence. Many employers offer sick pay above the statutory minimum, but this isn’t true for everyone, with around a quarter (26%) of workers estimated to receive only the minimum. Employees who work in service, leisure and caring sectors are less likely to receive additional employer support – jobs that by their very nature face higher risk of transmission and are less likely to support remote working.

The UK performs towards the bottom of OECD countries in terms of the generosity of its sick pay. Workers with Covid-19 or who are isolating are entitled to statutory sick pay of £95.85 a week, but this excludes the lowest earners with weekly pay of less than £120, who have to apply for support through other benefit schemes.

The average mandatory sick pay in OECD countries covers 70% of an eligible employee’s lost earnings during a quarantine period, but in the UK this on average is only 10%.* While the government has made sick pay more accessible by waiving waiting periods and extending benefits to the self-employed, these are minor adjustments compared to the approach taken in other countries to help people less able to miss work.

Beyond having higher statutory sick pay to begin with, many other countries have also provided support over and above existing entitlements. In France and Belgium, workers isolating receive a nominal allowance alongside statutory sick pay. Canada, New Zealand, Spain and Ireland have introduced sickness benefits for Covid-19 that go above statutory levels. England, Scotland and Wales have recently introduced £500 payments to support low paid workers to quarantine, but it’s still low by international standards and some areas have reported insufficient funds to meet demand.

2. Temporary accommodation and supported isolation

Other practical reasons people may be unable to self-isolate are their living situations or access to supplies – for instance, if they live in cramped housing or are unable to arrange for food or other essential deliveries throughout the quarantine period. In England, roughly 800,000 households live in homes that are overcrowded, increasing the risk of transmission to entire families or households.

One way around this is to provide designated facilities or accommodation support for people who need to quarantine. Modelling suggests that institution-based isolation is roughly three times more effective at reducing community transmission than home-based isolation, due to increased compliance.

Some countries have provided alternative accommodation to help people self-isolate, including in France, Italy, Denmark, Finland and parts of Canada. Eligibility criteria differ in each country, but in these countries tend to be set up on a voluntary basis and prioritise individuals who live in crowded housing or with high-risk individuals. Parts of China, Vietnam and Singapore have taken more extreme measures and have made quarantine mandatory for positive cases and direct contacts in purpose-built isolation centres, which makes it easier to enforce adherence and to monitor patients for deterioration.

When it comes to support for groceries and essential supplies, the picture is mixed. Some countries offering designated quarantine accommodation also provide free food and supplies for those isolating (e.g. Denmark, Canada), but this isn’t the case everywhere (e.g. Finland). South Korea provides all individuals with daily necessity kits during the self-isolation period.

In many countries, support exists locally to help people with essential deliveries and home adaptations to isolate safely, but as in the UK they tend to be supported through volunteer networks and are not guaranteed for everyone in need.

Funding has been available since June in England to help local authorities support more people to self-isolate, but it’s not clear whether these resources have been adequate and what more is needed to help people stay in their homes effectively. Survey data has found that needing to go to the shops is one of the main reasons that people break self-isolation rules in the UK.

3. Reduced length of quarantine

Many countries have reduced the length of prescribed self-isolation to make it easier for people to comply, citing ‘pandemic fatigue’ and concerns over the public’s growing resistance to quarantine. The UK dropped the number of days that symptom-free close contacts have to self-isolate from 14 to 10 days. Under current proposals, frequent testing could replace the need for self-isolation for close contacts altogether, who would only have to quarantine if they test positive.

Other countries have reduced quarantine lengths for close contacts, from 14 days to 10 in Italy, Finland and Norway, and seven in France and Belgium. However, there is mixed evidence that reduced quarantine lengths will improve adherence, and in September the WHO warned against this approach as it increases the likelihood that people may stop isolating when they’re still infectious (different standards and guidelines exist for confirmed positive or symptomatic cases).

Some countries have already reduced isolation periods contingent on negative tests. This is the case in Belgium, where exposed contacts can stop self-isolating after seven days with a negative result. In Germany and Denmark, there are no minimum prescribed isolation periods, but exposed contacts must have repeat negative tests or approval by local authorities.

These approaches rely on sufficient numbers of appropriately sensitive Covid-19 tests that are equitably accessible – which some in England have flagged as a concern and a potential barrier to rapid testing programmes.

4. Penalties

One way the UK has attempted to improve compliance to isolation is through financial penalties for people violating protocols. When NHS Test and Trace began, there was no legal duty to comply with self-isolation rules, given fears that enforcement could have the unintended consequence of deterring people from coming forward. This changed in late September in England, when the government introduced fines starting at £1,000 that rise to £10,000 for repeat offenders or serious breaches, and can come with criminal charges. In November, Wales introduced similar fines for individuals failing to self-isolate. 

Other countries have adopted similar strategies, including Spain, Germany, Norway, Taiwan and South Korea, where fines and/or jail sentences may be applied to anyone breaking isolation rules. France is taking a different approach and considering positive incentives alongside financial penalties, with some localities proposing that people who abide by protocols receive €30 per day of isolation (so far France has avoided coercive measures to enforce isolation). Many countries have strict penalties in place for people who break lockdown or fail to quarantine after international travel, but much less information is available about how these penalties apply to positive cases and contacts who fail to isolate.

There are mixed views on how effective fines and other penalties are in improving adherence. Some international evidence has shown that these charges can help mitigate the spread of Covid-19, but others have found that increased sanctions had minimal effect. As these interventions are very context and culture dependent, it can be difficult to draw conclusions from international experience.

In the UK, data is not available on the number of penalties issued for self-isolation violations and how much they have influenced behaviour, but we know that for other breaches (such as breaking quarantine for international travel) the number of fines issued has been low. And without robust systems for monitoring and tracking compliance, it can be difficult to detect when and where violations are happening, which limits the usefulness of the intervention.    

5. Monitoring

Unless they change people’s behaviours, test, trace and isolate programmes are futile, making ways of tracking and understanding adherence a key part of the puzzle.

Countries have pursued a range to tactics to monitor compliance, including random physical checks or phone calls to people quarantining, as in parts of Australia, Spain, Denmark, Portugal and France. On the more extreme end of the spectrum, several countries (e.g. Singapore, Taiwan, South Korea, Iceland, Italy and Ukraine)  have used geolocation data to monitor the movements of cases to make it easier to enforce and track compliance of self-isolation restrictions.

While England has introduced high fines for violations, we have comparatively little monitoring arrangements in place. NHS Test and Trace makes follow-up calls to advise those self-isolating, and can refer suspected violations to local authorities or the police. Information is collected on the outcome of these calls, as well as applications and payments for isolation support to help track levels of isolating cases. To increase compliance, Test and Trace call handlers have been asked to increase contacts with those self-isolating and police forces to increase checks in high incidence areas.

Increased monitoring can be difficult to implement, potentially requiring new legislation, data-sharing and cross-departmental collaboration. It can also involve enormous trade-offs if the tactics are seen as intrusive to the public. For example, efforts in Belgium to enforce quarantine rules were hindered by municipal authorities lacking capacity and access to data on individuals and a fear of damaging relationships with local residents.

The range of strategies pursued internationally may highlight the need to consider cultural norms and context. But given the consistently low adherence to self-isolation in the UK, it is clear that we need to rethink the levers being used to monitor compliance.

Placing vulnerable communities at the centre of policy 

A critical tension inherent to test, trace and isolate programmes is that the people who are least able to get tested and isolate are also the most vulnerable to Covid-19. There is now overwhelming evidence of structural inequalities that make people living in poverty, who have crowded housing, or work in essential, public-facing jobs disproportionately affected by the virus. Black and Asian and minority populations are overrepresented in these groups, which is a key reason these communities have a higher risk of infection and death from Covid-19.  

To improve compliance, the UK has relied heavily on strategies that fail to account for the needs of different populations or place the most vulnerable communities at their centre. Proposals to gradually replace isolation with mass testing could harm populations that are less well placed to access testing – particularly if tests are made more readily available at a charge. 

Punitive fines are regressive and could burden populations that have already been hit hardest by the coronavirus. For instance, early data suggests that young men from Black, Asian and ethnic minority communities are 1.6 times more likely to be fined than white people for breaking Covid-19 restrictions. Enforcement can be a key tool in supporting adherence, but it is essential that any unintended consequences for inequalities are carefully considered, and that people without appropriate resources and support to self-isolate are not unfairly penalised. Further monitoring needs to be done about how tactics might impact vulnerable and high-risk communities differently.

While the UK has increased financial support to help low-income people to self-isolate, these payments are still low by international standards. Other countries also do more to provide temporary housing support and resources to people isolating at home, or quarantine contacts separately – something that might be more feasible now given the number of vacant hotels, dormitories and event facilities due to lockdown measures. 

The different options described in this piece can be pursued simultaneously, and indeed a review by the NHS Test and Trace board found that countries with the most effective systems used a mix of incentives and enforcement measurements to improve compliance. The government has taken a positive step in committing to better understand the barriers that communities face in isolating and introduce additional measures to promote adherence, but this has overall received far less focus and resource than testing and tracing capacity.

There is scope to make further changes if overall adherence remains an issue while doing more to support vulnerable populations who are less able to isolate. Doing so may require investment, but the costs of which may well be small compared to continued levels of uncontrolled spread.