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Views And Reviews

Why Scotland’s slow and steady approach to covid-19 is working

BMJ 2020; 370 doi: (Published 06 July 2020) Cite this as: BMJ 2020;370:m2669

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  1. Devi Sridhar, chair in global public health, director12,
  2. Adriel Chen, researcher, foundation year 1 doctor23
  1. 1University of Edinburgh Medical School
  2. 2Global Health Governance Programme
  3. 3NHS Lanarkshire
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Deaths and new infections from covid-19 are falling to low levels in Scotland. Devi Sridhar and Adriel Chen look at how the country is on course to eliminate the virus

In April 2020, the Scottish government published a framework for decision making on covid-19 which notably included that there would be no acceptable number of covid-19 cases, and that no one would be intentionally exposed to this virus.1 This framework set the objective clearly: to drive the number of cases as close to zero as possible. From that objective a strategy and game plan could be worked out.

In the last two weeks of June, Scotland had a decreasing number of cases, hospitalisations, and deaths from covid-19, leading to a continued push for a “zero covid” Scotland.1 In addition, the positivity rate—the number of people testing positive out of the total number of people tested—has fallen to under 0.5% on most days. As Scotland has a land border with England and is part of a global world, this does not mean elimination with no cases ever. It does, however, mean working towards ending community transmission and local cases, and moving towards a future where the main risk of covid-19 is from imported cases. These need to be quickly identified, traced, and all individuals quarantined. An elimination strategy is optimal for public health, the economy, and society, as it allows maximum normality as lockdown eases, and avoids the halfway house that results from a high level of virus transmission and circulation.

Scotland used the time in lockdown, which began on 23 March, to build up a “test, trace, isolate, support” system, referred to as “Test and Protect.” This helped suppress the virus. Lockdown measures have been eased cautiously and in a stepwise fashion. This strategy involves testing symptomatic people, tracing contacts, isolating those who are carrying or have been exposed to the virus, and providing them with necessary support to meet their needs. Early on, Health Protection Scotland decided not to rely on an app for contact tracing, but to build up existing capacity within NHS public health boards.

Scotland also took a more cautious route out of lockdown, using phases that usually started two or three weeks after the rest of the UK.1 When the message in England switched to “stay alert” on 10 May, Scotland continued with the “stay at home” message. Even until 3 July, households were encouraged not to travel more than five miles from their home for leisure. Households are also encouraged to meet and interact with others outdoors, which is in line with increasing evidence on the lower risk of transmission outdoors.234 Clear messaging seems to be an important component of adherence to rules, given that the majority of people want to follow public health guidance but need to have clear instructions on what is and is not permissible.

A third component of Scotland’s approach is a high degree of trust in government and in the leadership of the first minister Nicola Sturgeon to manage covid-19 effectively, as a recent Edinburgh University study noted.5 In late March, the Scottish government established its own scientific advisory group to coordinate with the Scientific Advisory Group for Emergencies and provide advice tailored for Scotland. From its inception, transparency was encouraged and the Scottish government website published the membership of the group, as well as minutes and eventually background papers. Sturgeon and other key senior officials held daily briefings outlining the state of the pandemic in Scotland, as well as taking questions from members of the press, leading to intense scrutiny and debate on the measures being taken.

While Scotland is heading towards a possible zero covid-19 future, major challenges lie ahead. Firstly, Test and Protect must be strengthened to ensure it is catching all cases in the country and doesn’t become overwhelmed, especially when heading into winter when many of the symptoms of colds, respiratory infections, and influenza can overlap. Winter brings more people into indoor settings and early evidence indicates that virus transmission is more effective indoors.

Secondly, given the global pandemic has yet to peak, there is an ongoing risk of cases being imported to Scotland from the rest of the world. Increasing vigilance would require land borders, marine ports, and airports to be monitored.

Finally, citizens around the world will start to tire of the ever changing public health measures and messaging. This runs the risk of decreasing compliance over time and a reciprocal increase in new infections and local transmission. Therefore, there remains a small window of time to push infections to a negligible level, establish robust and real time monitoring, reopen schools full time, lift shielding for the vulnerable, reintroduce socialising, and get the economy up and running again. Scotland has taken a slow and steady path, but one that will hopefully lead to a more sustainable future.


  • Competing interests: DS serves on the Scottish government’s covid-19 advisory group and on the Royal Society DELVE initiative. Both are unpaid positions. AC has no competing interests.

  • Commissioned, not peer reviewed

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