Coronavirus (COVID-19): framework for decision making - assessing the four harms

Implementing the four harms approach

The four harms approach underpins our assessment of risk and harm, our development of options and restrictions and our ability to make decisions based on a broad appreciation of the consequences of our actions. The next section of this report defines the harms in more detail, explains how we have assessed each of the four harms – to produce ratings for each harm that inform decision making - and presents some of the key data we have used to arrive at our assessments.

What are the four harms?

The four harms encapsulate the multi-faceted harms of the crisis namely the direct harm of the disease itself, the wider health harm and the broader societal and economic impacts of both the virus itself and our necessary responses to it. The Scottish Government's approach is to suppress the virus to a very low level (the first harm) while seeking to minimise these broader harms. This approach has guided decision making concerning the easing of restrictions during the Route Map process.

Harm 1 represents the direct impact of COVID-19 and ratings for this harm are based on a consideration of transmission risk and the impact on R. The factors taken into account in arriving at the ratings include the setting, indoors or outdoors, the number of people potentially affected, the duration of the activity and the proximity of the people involved, the likelihood of droplet/aerosol production and spread and of touching surfaces and, finally, the possibility and ease of mitigations available. All of these factors are underpinned by the developing scientific evidence base, international experience and experience in Scotland. The highest risk activities are those that take place indoors in crowded, noisy environments with poor ventilation, many surfaces, physical space that makes distancing difficult (for example shared bathrooms, canteens, few entrances and exits) and social environments that tend to discourage distancing. The latter is very relevant for household meetings in private homes where maintaining distancing among family and friends is very difficult.

Harm 2 focuses on the indirect impact of COVID-19 on both health and social care services and wider impacts on public health. Key considerations influencing scoring for Harm 2 include anticipated impact on levels of excess non-Covid deaths and the effects of health and social service changes. The wider public health aspects considered are around physical and mental health and wellbeing. Particular attention is paid to services for the most vulnerable in the community who are often the section of the population likely to suffer most from COVID-19 infection. The physical and mental health consequences of restrictions that limit the possibility of social interaction and exercise are also seen as extremely important.

Harm 3 overlaps to some extent with the wider physical and mental health impacts of Harm 2 so, as part of the assessment process, care is taken not to double count impacts. Key considerations around Harm 3 are safety and security, learning and development, social capital and community cohesion, loneliness and anxiety, economic security, and trust in Government and the social contract. These wide ranging considerations are analysed through a variety of data from health, justice, education and direct public polling. Particular attention is paid to the needs of children and young people whose wellbeing and development are particularly impacted. The impacts of restrictions on those living alone are also a key concern in terms of social isolation. Equalities featured strongly in assessing social harms as we know that diversity groups such as women, disabled people, ethnic minority communities and those from lower socio-economic backgrounds have experienced particular disadvantage. The damaging effect on poverty and inequality may be profound.

The dimensions of economic harm, Harm 4 include the direct impact on the economy and are inter-related to health and social harms through the indirect effects that a weaker economy can have on health and society through, for example, the impact of unemployment. The scarring in terms of social and health effects will come via the longer recovery period as we deal with the impacts of higher unemployment and financial insecurity and hardship for many businesses, individuals and households. The impacts will intensify the longer the restrictions on our normal way of life continue: we will see more businesses unable to recover and we risk the scarring effects of unemployment.

Key considerations around economic harms were the parts and sectors of the economy affected as well as their relative importance pre-COVID-19. The consequences for businesses in terms of lower turnover and cashflow, jobs furloughed, as well as the level of capacity at which they could operate, were important considerations. The length of time that economic activity was impacted and the implications on unemployment and redundancies was considered in conjunction with the secondary impacts on health and social harms (harms 2 and 3).

Decision making based on the four harms

During the Route Map decision-making process, which saw the gradual and careful easing of restrictions from the initial lockdown of March and April, the Scottish Government made decisions about which restrictions to ease and when (and also about which new protective measures to implement – such as the use of face coverings).

As set out in the 'Framework for Decision Making'^[39], the Scottish Government's approach is to suppress the virus to a very low level (the first harm) while seeking to minimise the broader harms of the crisis. This approach has guided decision making and has introduced sometimes complex considerations. For example, it follows that, in making decisions about necessary restrictions on activities and settings, not only is the impact on the first harm considered (e.g. on their transmission risk) but also the impact on the broader harms, in order to both suppress the virus and then minimise the broader harms. Consequently, decisions are not taken solely on the basis of comparing the transmission risk of one setting against another.

Potential options – individual and combinations of measures – were assessed for their impacts on the four harms (in the way set out in this document) and for their viability, for example taking account of how easy they are to communicate and understand, the likelihood of public compliance, the proportionality of any impact on human rights and other legal considerations. Broader considerations also include equality impacts and consideration of tailoring measures, for example to specific geographies and sectors. This is in recognition of the fact that the crisis is impacting differentially on subgroups of the population and different parts of the country.

Assessments for each of the measures helped to inform the various Route Map decisions, which were made by Cabinet and then implemented through regulations and guidance as appropriate.

To assess the impact on the four harms, a wide range of evidence and data was used (including information provided by relevant policy and operational teams) including for each option:

• Specific features – the key aspects of the option to be assessed;
• Scale - how many people might be affected by this option (e.g. workforce, users of service);
• Equalities - what we know about the people affected in terms of characteristics, gender, age and other characteristics;
• Occurrence - how often will this occur: daily, weekly, periodically, on demand;
• Geography - does this option affect all areas of the country; are some areas more impacted;
• Mitigations - what mitigation options are or could be put in place to reduce the risk of the option; and
• Alternatives - What alternative approaches could be developed to deliver this option?

The range of options for restrictions and other measures – easing, maintaining, (re)introducing – were assessed using the best available evidence and analysis.

In undertaking this assessment we considered both the risk and impact on individuals and the risk on the population as a whole. Individual use assessments take into consideration likely risk associated with getting to and from a setting, for example, as well as the risk in the setting itself. Overall transmission risk, in contrast, takes into account both how many people participate in or use a particular setting or activity and the interaction that such use or participation is likely to generate indirectly. (For example, we know that opening schools typically leads to much more social interaction by parents and carers unrelated to the school setting – e.g. enabling more to return to workplaces etc.)

As scientific knowledge and practical experience evolves we update assessments as new evidence and information becomes available, mitigations are put in place, and everyone becomes more familiar with the actions needed to participate safely in a range of activities.

Conclusion

We are aware that any restrictions put on our normal way of life have serious consequences, therefore any decisions we make have to consider not only the impact on public health, but also wider healthcare needs, society and the economy. Within this report, we have drawn together evidence on the various harms and wider impacts caused by the crisis and some of the criteria we use to assess evidence. Evidence is still emerging and the scale and nature of the impacts will change over time. Our evidence comes from a range of sources, and is brought together with experience and insights from other countries, institutions (domestic and international) and our own stakeholders.

High levels of compliance with the core measures of physical distancing, good hygiene, and observance of the specific restrictions related to each level need to be sustained.

We recognise that public tolerance of the distancing measures is hard to sustain and that these measures, in turn, have wider impacts on society and the economy. Central to our considerations is a recognition that the crisis is impacting differentially on subgroups of the population and different parts of the country. A concern with issues of equality is at the heart of our decision-making and analysis going forward.

This document focusses on the evidence and analysis in relation to the four harms that informed decision making during the Route Map process from May to September. To maintain transparency in the decision-making process during the epidemic, we intend to provide further evidence and analysis that has been used to support the levels approach within the Strategic Framework in the near future.