12 October 2020

Roger Steer is an ex-NHS senior manager, director of finance and chief executive who has since 1996 worked as a management consultant, interim executive and most latterly as an adviser to local authorities and expert legal witness to the major reconfigurations and transformations planned in England.

Assessing Scotland’s Covid-19 response

Roger Steer would like to think Scotland could avoid the mistakes and blunders of the English NHS. But does the evidence stack up in the case of the efforts to contain Covid-19?

THIS article was originally conceived as a wider perspective on healthcare issues but it turns out that by focussing on Covid-19 and Scotland we can avoid muddying the waters. There is enough to say on these alone without complicating the story further.


The basics of the story are uncontested: despite healthcare being part of the domestic powers of the Scottish government for the past 20 years the settlement has remained “safe” in the SNP’s hands. Continuity and not rocking the boat has been the watchword rather than the vigorous pursuit of an aggressive Scottish policy to address local needs.


So when the pandemic emerged as an issue at the beginning of 2020 with early (and misleading) information that the future death rate would be 3–4% and a level 4 event was triggered (initially), a test was set for Scotland. Would it perform better than the UK as a whole? Or is the United Kingdom firmly in place as the basis for effective action on the big healthcare questions of the day?


It would be easy to tar Scotland with the many criticisms of the UK government. The public inquiry the UK government will seek to avoid will surely identify lack of preparedness despite clear warnings (the UK government actually reduced the strategic stock of personal protective equipment over the last five years); lack of responsiveness (it has been estimated that when the disease was spreading exponentially in March the extra 10 days of delay before lockdown will have killed thousands of people); lack of capacity (in testing, in intensive care facilities and staffing, and in the system as a whole causing the cancellation of most non-emergency activity); callous, wilful blindness to the consequences of discharging untested infected people into nursing homes and in failing non-covid patients requiring lifesaving treatment in the meantime. Other countries did noticeably better but it appears that Scotland remains in lockstep with the UK rather than with either its Celtic or northern European cousins.


The questions that hover are:

  • Do we know how Scotland compared in performance to fellow Celtic/Nordic countries?
  • Given the self-government of health and social care for the last 20 years should Scotland have performed better on healthcare issues and pandemic management?
  • Are there lessons to be learnt?


In seeking to answer these questions we can examine the various reports and newspaper articles that address the Scottish healthcare system and how it compares with the rest of the UK, in particular the Public Health Scotland Review which in 2015 found “lack of coherent, coordinated public health leadership in Scotland” (the follow-up report has been delayed by Covid-19!).


None had identified concerns about future pandemics. Both the UK and Scotland have been focussed on “health improvement”, “integration of health and social care” and when push came to shove there have only been small differences between the countries in the UK when it came to performance in pandemic management but much larger differences between mortality rates across comparable countries.*

This represents a mixed bag of results. Smaller populations and self-government of borders and public health do not seem to deliver results in themselves. The UK has been worse than others (apart from Belgium). According to the Centre on Constitutional Change the variation in excess deaths across the UK may show a slightly lower level of excess deaths in Scotland because Scotland already has a high level of deaths anyway!


In fact any advantage Scotland enjoys over the UK is small and still leaves Scotland worse than the Ireland and leading European nations and is probably a result of taking advantage of lockdown earlier before the disease had spread, as occurred in London and parts of England.**


Readers will be aware that there is controversy about how to count deaths, how deaths are registered and coded, and thus how comparable figures may be from one country/region to another: but the overall conclusion is that if self-government was to be justified by better results on healthcare and in pandemic management, Scotland has only had modest success.


Could and should Scotland have done better?

In common with the UK, Scotland has performed badly on Covid-19. It seems to have more in common with England than to its fellow Celtic tigers, who are in turn a mixed bunch with no unifying identity or competitive advantage in pandemic management, or for that matter in healthcare delivery with quite different systems existing across countries. Thus Ireland has a more private-insurance-based system while the Nordic countries have variations of the European social-insurance-based model with wide ranges of public funding and public/private mixes in actual delivery systems.***


Given the freedom to develop its own healthcare identity it seems that Scotland, despite the powers to do so under devolution, has chosen to remain within funding constraints (preferring to spend within budget rather than pay for additional services out of increased taxation) and despite the increased human need in Scotland, where public health and inequality remain far worse than in England, content to follow a similar set of policies as England.****


What lessons can we take?

Self-government is not a sufficient tool. It’s what you do with the tool that is the measure of success.


Continuing to ape policies developed in England to address English healthcare problems when Scottish needs are more pressing and requiring more immediate action is not justified. Simply adopting a follow-my-leader approach has led to Scotland being almost as unprepared, unresponsive, under-resourced and failing in its pandemic management as the rest of the UK. In fact if any difference can be discerned in health policies it is that Scotland has pursued bed reduction more vigorously than the UK as a whole in the name of integration of healthcare with medical beds falling by more than 10% over the last 10 years despite longer term demographic trends pointing to the requirement for approximately 40% more beds.


This may require reprioritisation, additional funding, and more thoughtful local approaches looking to the success of other countries, although not necessarily from close cousins or neighbours.


In the end success in healthcare is a combination of investment, hard work and good management taking the right choices. This website has pointed in a review of the work of Ian Rankin to the tendency in Scottish culture to identify deeper malevolent forces at work and to portray the working class as undeserving and self-destructive. It may be the time for the Scottish people to really take control of its health services.


  • Parts of this article were updated on 14 October 2020 at the request of the author.