By stewartb – a long read

We can only speculate what profile the UK Covid-19 Inquiry will end up giving to different sources of evidence on the Scottish Government’s response to the pandemic. How will the Inquiry weigh what it receives from dispassionate experts in comparison to what is favoured by the politically partisan? Will the Inquiry’s reporting major on WhatsApp messaging and alleged political motivation as its public hearings in Edinburgh appeared to do, at least according to media coverage? Regardless of what emerges, will BBC Scotland still trawl the Inquiry’s findings for that precious phrase which will deliver the best opportunity for a headline to apportion and amplify political ‘blame’ rather than substantive public health learning?

Little of the expert evidence invited by the Inquiry of relevance to Scotland has been commented upon by the news media, and certainly not by those with a ‘public service’ remit! As a consequence, many in Scotland – one fears a majority – may be (i) unaware of the positives evidenced by independent witnesses regarding the Scottish Government; (ii) less than fully informed of the context in which those governments in the UK with only devolved powers had to operate; and (iii) lack the perspective that knowledge of comparative analysis of pandemic responses and outcomes in the four UK nations and internationally brings. This is a modest attempt to redress the balance, to substitute ‘light’ in place of ‘heat’!

PART 1: Tracking the responses of governments

The following considers written evidence to the Inquiry’s Module 2 from Thomas Hale, Professor of Global Public Policy at the Blavatnik School of Government, University of Oxford. Professor Hale leads the Oxford Covid-19 Government Response Tracker (OxCGRT), a major data gathering and analysis project with an international scope to track government policy measures introduced in response to the pandemic. The OxCGRT was initiated in March 2020 and claims to have become the ‘primary database used globally for this type of comparative information’ – presumably why the Inquiry wanted its input.

Source: Hale, Thomas (2023) Module 2: Oxford COVID-19 Government Response Tracker Evidence for UK Covid-19 Inquiry. Document INQ000257925: (https://covid19.public-inquiry.uk/wp-content/uploads/2023/10/11154221/INQ000257925.pdf )

(The methodology used by OxCGRT is explained in an annex to its evidence report.)

Lessons from international experiences

Based on international evidence of pandemic responses and related outcomes analysed by OxCGRT, Hale emphasises the importance of six factors for governments when constructing effective interventions:

• Speed matters – the timely adoption of Non Pharmaceutical Measures (NPIs) is a key factor in reducing transmission of Covid-19, with evidence that delay of even a single day significantly increased death toll.
• Strength matters – the stringency of policy interventions e.g. stay-at-home measures, school closures, are key to reducing transmission of the virus and mitigating adverse health effects.
• Effective use of test, trace and isolate measures – these both limit health impacts and reduce the need for more restrictive policies.
• Economic support bolsters compliance – stronger economic support policies led to better compliance with the NPIs.
• Prolonged restrictions can have costs – some of which only becoming evident over time.
• Policy responses have different effects on vulnerable and non-vulnerable people – the differential impact of policy interventions on different groups have even become evident in places e.g. South Korea where the government response to there pandemic has been widely praised.

The above list of factors taken with evidence of outcomes provides a basis for examining responses by governments within the UK. However, implicit in all this, arguably, is the severe challenge that faced all public authorities – especially given incomplete knowledge of the virus at the outset – when designing effective interventions as timeously as possible within their own complex and evolving public health ‘situation’,  with multiple inter-dependencies and inevitable trade-offs. And let’s not forget the ‘local difficulty’ of the restricted powers available to devolved governments in the UK. None of this is straightforward – regardless of the retention or otherwise of WhatsApp messages!

Comparing government responses

What follows are extracts from the written evidence submitted to the Inquiry by Professor Hale:

From Para 44 – on speed of initial response in 2020:

• ‘the UK was slower than the average country to adopt stricter measures across nearly every domain of response’
• ‘The UK government was particularly slow to adopt international travel restrictions and school and workplace closures after the initial cases, when compared to other countries.’

From Para 45 – comparing responses in the four nations:

• ‘Relative to the spread of the virus, measures came into force in England slower than in Scotland, Wales and Northern Ireland …’
• ‘The viral spread began first in England.’
• ‘In particular, relative to the spread of the virus, the devolved administrations implemented stricter policies on school and workplace closure as well as restrictions on public events before Westminster.’

Para 46 – ‘it is therefore quite likely that the health impacts of Covid-19 in the UK in Spring 2020 would have been lower if policy responses had been more timely.’

Para 47 – ‘Relative to the spread of the virus, the four UK nations adopted more stringent policies more slowly than the average country in the world. England was notably “slow” to react to the virus.’

Para 50  – on travel restrictions:

• ‘The United Kingdom enacted international travel controls relatively late compared to other countries.’ Of course, the legal powers to control the UK’s external border lay with just one government in the UK.

Overall assessment and international rankings

From Para 56 – ‘the UK experienced a combination of relatively high health impacts (here measured in deaths per capita), economic impacts, and long periods of restrictive policies.’

The following table gives the international rankings for the four UK nations for the metric ‘deaths per capita’ based on data provided in Para 56.1 of Hale’s evidence to the Inquiry. The higher ranking – the lower the number – equates to a relatively higher number of deaths per capita.

	Global countries’ ranking	European countries’ ranking
England	19th highest in terms of deaths per capita	15th highest
NI	52nd	34th
Scotland	38th	27th
Wales	30th	21st

The next table summarises the international rankings for total number of days spent under stringent policy measures (days spent above the OxCGRT’s Stringency Index level 70) based on data provided in Para 56.2. In the table, the higher ranking – the lower number – equates to higher number of days spent under the stringency measures.

(See Annex to the evidence document for explanation: the OxCGRT tracks time spent above index levels 60, 70 and 80, the latter being the most stringent).

	Global countries’ ranking	European countries’ ranking
England	85th	18th
NI	82nd	15th
Scotland	66th	10th
Wales	57th	6th

The Hale report adds (Para 58) – ‘While the policy responses of the four UK nations are more similar than not, in part reflecting the limits of authority of the devolved nations, some notable differences emerge. Westminster tended to lift restrictions in England in advance of other nations (e.g. schools and workplace closures) and at certain points had less stringent policy responses than other nations (e.g. public events, workplace closures, and stay-at-home requirements).’

From the same section of the report, the Inquiry also learns that:

• ’England and Northern Ireland tend to have less stringent policies than Scotland and Wales during the second half of 2020.’
• ‘For the latter part of 2021, Northern Ireland had the most stringent measures whereas England had the least stringent measures of the four nations.’

And the Inquiry has received this conclusion: ’Considering the importance of quick and strong policy responses, it is then perhaps unsurprising that England had also clearly higher peaks in population-adjusted daily deaths across the pandemic.’

Hale’s evidence also explains (Para 80) that there is less variation in the cumulative number of days spent above Stringency Index value 60 (i.e. at a level less stringent than Index value 70) across the four nations than there is when it comes to comparing cumulative time spent at higher levels of stringency. It notes that in the first wave of the pandemic in 2020, there is a high degree of consistency: the most variation was in the ‘use of internal restrictions of movement between cities and counties’.  However, by the second half of the pandemic from mid 2021 onwards, ‘it is clear that Scotland, Wales and Northern Ireland were more likely to use stringent policy measures than England’.

And then crucially, in Para 61 –  ‘For the first half of the pandemic, until July 2021, the responses of all the four devolved nations were of a relatively similar degree of stringency. Despite this, England consistently recorded more daily deaths per capita during each wave of the pandemic.’

Speed of response by policy domain

Hale’s evidence charts the speed of policy response in the four nations of the UK in some detail. This is measured and compared by determining the number of days taken to respond (i) after the first case of Covid-19 in the relevant population had been confirmed, and (ii) after the 100th case had been confirmed. The results are striking in that the responses by the Westminster government for England are mostly much slower and never faster than the policy responses in Scotland. In no policy response is Scotland slowest of the four nations: in many cases the policy reaction here was faster. (Only one of the two charts given in the Hale report is reproduced here viz. on speed of response after the 100th confirmed case. This is chosen rather than that charting response times after the 1st case as the report considers the 100th case benchmark to be the more useful of the two.)

In the chart below, Hale compares the cumulative number of days that different governments had a stricter policy in place. In many policy areas there is little difference across the four UK nations but where a difference is evidenced, England has its strict policies in place for shorter time periods except over ‘stay-at-home requirements’.

The above chart also indicates the period of time that governments in the UK maintained restrictive policies at different Stringency Index levels over all.

Merits of an ‘elimination strategy’?

Hale argues (see Paras 67-68) that countries which adopted an ‘elimination strategy’ in responding to Covid-19 did so by having a reasonably effective testing and contact tracing regime and by exerting stringent control over international borders. He lists South Korea, Japan, Australia, New Zealand, Singapore, Taiwan and ‘some Caribbean nation’ as having success by adopting an elimination strategy. According to the evidence to the Inquiry, it involved this broad pattern of responses: (1) crushing the initial wave with restrictive policies; (ii) developing testing and contact tracing to minimise community transmission; (iii) enjoying relative openness alongside fast, short, stringent and localised restrictions introduced immediately to prevent small outbreaks growing into large ones; (iv) stringent international travel controls.  Hale concludes that these countries: ‘enjoyed the envious position of experiencing widespread Covid-19 transmission only after high-level of vaccination had been achieved’.

In the context of this conclusion provided to the UK Covid-19 Inquiry, the content of an article published in the British Medical Journal (BMJ) on 3 August 2020 is ‘interesting’: ’Covid-19: Should the UK be aiming for elimination?’ (https://www.bmj.com/content/370/bmj.m3071)

It reports: ’Scotland’s first minister, Nicola Sturgeon, told a press briefing on 28 July that she had suggested that all four UK nations align “around a strategy that is effectively about trying to eliminate the virus.”

Ms Sturgeon is quoted further: “If we could all align around an approach that is very explicitly about driving this virus down to the lowest possible level and allow our policy decisions to flow from that, then I think that would be a good step forward, as opposed to having an approach that allows the virus to hover around at a certain level and then hope it doesn’t overwhelm you”.

The author of the BMJ article notes, ‘This elimination approach has been advocated by the non-official advisory committee Independent SAGE: “Northern Ireland and Scotland have explicitly adopted zero covid as a strategy, and the Republic of Ireland has basically been working to that way,” said Susan Michie, director of University College London’s Centre for Behaviour Change, who sits on both Independent SAGE and the official SAGE, as well as its behavioural science subcommittee, SPI-B.’

Michie goes on:“There is no reason why as a joint couple of islands we can’t get to covid zero if we all pull in the same direction,” she added, holding up New Zealand as “proof of principle.”She added, “An elimination strategy is much more feasible for us than a country on mainland Europe.”

The BMJ article added: ‘A spokesperson for Northern Ireland’s Department of Health said that: “a very robust approach to tackling and maximally suppressing covid-19 amongst our population” was being taken and that cooperation with the Republic of Ireland through a formally agreed memorandum of understanding had been “central to controlling the virus on both sides of the border.”

And whilst some places, notably Sweden, took an approach which avoided mandatory lockdowns, this BMJ article from 2020 notes: ‘Figures from the Office for National Statistics this week showed that it was not Sweden but the UK that had been hit much harder by the covid-19 pandemic, as England had the highest levels of excess mortality in Europe during the first half of 2020.’

PART 2: STATISTICAL EVIDENCE ON OUTCOMES

This part of the blog post summarises evidence to Module 2 of the Inquiry regarding pandemic ‘outcomes’: these are expressed in terms of mortality statistics for 2020-2022 for the four countries of the UK. It is based on written evidence submitted by Professor Sir Ian Diamond, the CEO of the UK Statistics Authority (UKSA) who is also the UK government’s ‘National Statistician’. It’s hard to argue against this statistical evidence meeting the UK’s ‘gold standard’!

Source: Additional Witness Statement of Professor Sir Ian Diamond (11 September, 2023) (https://covid19.public-inquiry.uk/wp-content/uploads/2023/10/10174513/INQ000271436.pdf )

Scotland: lowest age-standardised mortality rate among UK nations

The UKSA evidence (in its Table 5, reproduced below) reports that the age-standardised mortality rates (ASMR) of death involving Covid per 100,000 population was substantially lower in Scotland than in England and Wales: 124.9 per 100,000 in Scotland compared to 145.0 and 144.6 in England and Wales respectively. The rate in Scotland was also lower than that in NI (130.7 per 100,000). Among the English regions, only the South-West of England has a lower age-standardised mortality rate than Scotland. (‘Age-standardised’ rates are used to permit valid comparisons between groups with different age distributions and population sizes.)

(The UKSA evidence paper uses the term ‘due to Covid’ when referring only to deaths where the underlying cause of death is Covid; it uses the ‘involving Covid’ when taking into account all of the deaths that had Covid mentioned anywhere on the death certificate, whether as an underlying cause of not.)

Scotland: lowest percentage increase in deaths above age-standardised average

The number of excess deaths registered during the period March 2020 to February 2022 in each of the four UK nations is shown in the UKSA’s Table 13 (reproduced below). It provides statistics on excess deaths in two ways – by number of deaths above the average ex

pected value and above the average age-standardised mortality rate. It also provides these statistics for the time periods associated with three lockdowns – March to June, 2020; August to December, 2020; January to May, 2021.

It is now widely accepted that ‘excess deaths’ is the most objective and comprehensive metric for comparing the deadly impacts of the pandemic between different countries and regions – it removes variability and uncertainty in determining the role of Covid in the cause of a death and it takes account of all indirect and potentially hidden impacts of the pandemic on population health and mortality.

Across the pandemic period to February 2022, the table gives the levels of excess death above the average over the prior five years for the UK and its four nations. At 9.5% Scotland has a marginally higher rate than Wales (9.2%) and substantially lower than England (11.9%) and NI (11.5%).

Looking at each of the three lock-down periods in turn using the same metric, Scotland had the second highest level of excess deaths above the average for the period of the first lock-down but by far the lowest during subsequent periods. In all cases, the percentage increase above the average was substantially lower in Scotland than in England. It is notable that the scale of excess deaths above the five year average drops much more substantially in Scotland from August 2020 onwards than in the other UK nations.

The table also reports on the percentage above the average for the pandemic period to February 2022 using age-standardised mortality rates (ASMR), the measure best suited to such geographic comparisons. On this metric Scotland has the lowest percentage increase in excess deaths i.e. the least tragic of all the tragic outcomes across the UK. Once again the figures for Scotland show a more substantial drop off from August 2020 onwards.

The UKSA also provides evidence on excess deaths within the English regions for the whole period to February 2022. On the percentage of excess deaths above the average, the value for Scotland (at 9.5%) is lower than any English region bar the South-West. Using age-standardised data, Scotland (at 3.9%) is also lowest, again bar the South-West.

End note

For the avoidance of doubt, the objective of this blog post is to highlight information and insight evidenced by authoritative, dispassionate sources and in this way, to offer a more objective and more balanced view of pandemic responses and outcomes in Scotland. It is NOT to whitewash errors or shortcomings of government. However, it most definitely is to counter shortcomings in the reporting of evidence to the Inquiry of relevance to Scotland by BBC Scotland and most of the mainstream media here.

For more on the topic of omissions in media reporting, see: ‘The Covid Inquiry evidence unreported by BBC Scotland – can ‘bias by omission’ get any worse?’ (https://talkingupscotlandtwo.com/2024/01/28/the-covid-inquiry-evidence-unreported-by-bbc-scotland-can-bias-by-omission-get-any-worse/ )

Taking all the above together, the evidence available to the UK Covid-19 Inquiry paints a picture of the Scottish Government’s response to the pandemic and related outcomes so different from what has been shared with the public by BBC Scotland and most of the mainstream media that for some it may seem barely believable!