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

Sets out the four harms process for assessment used to establish when coronavirus restrictions could be safely lifted after lockdown and the scientific evidence underpinning the decisions.


This paper provides an overview of key analysis and evidence on the 'four harms' in support of COVID-19 decision-making.

On 7 May 2020, we published an overview of key analysis and evidence in support of our COVID-19: Framework for Decision Making. We set out the four harms approach and gave examples of the issues under consideration.

In this document, we describe how the four harms approach works in practice and present evidence to illustrate how we used the four harms to support decisions about activities and restrictions through the Route Map process. A subsequent publication will explain the four harms approach in the context of the recent development of protection levels.

We are making this information available as part of our commitment to bring transparency to our work and decisions on the crisis and to support understanding and public engagement with some of the very difficult issues that we face.

In this paper, we recognise four areas of impact - the 'four harms':

  • First, the virus causes direct and tragic harm to people's health and we need to consider what aspects cause increased risk of spread of the virus and who is most likely to be affected. Key indicators include the numbers of COVID-19 positive cases, hospitalisations and deaths along with the reproductive number, or R-value.
  • Second, the virus has a wider impact on our health and social care services in Scotland; we need to consider how people are using those services and how this impacts on non-COVID-19 health harms. In this paper, we focus on excess deaths, use of NHS services, physical and mental wellbeing.
  • Third, the restrictions which Scotland, together with the other UK nations, has necessarily put in place to slow the spread of the virus affect our broader way of living and society, including, for example, the negative effects of increased isolation, particularly for those living alone, and the impact on children's well-being from closing schools. The effect on poverty and inequality may be profound and the impacts will intensify the longer the restrictions on our normal way of life continue. We have identified six dimensions of societal impact and present headline indicator figures for each.
  • Fourth, along with the wider negative impacts of the global pandemic, the lockdown and continued restrictions have had an enormous impact on our economy. This is unprecedented and is causing deep uncertainty and hardship for many businesses, individuals and households. We will see more businesses unable to recover and we risk the scarring effects of unemployment and along with permanent structural damage to our economy.

These harms are related: health harms impact on society and the economy, just as the societal and economic effects impact on physical and mental health and wellbeing. Navigating the right course through the crisis will involve taking difficult decisions that seek to balance these various, inter-related harms so as to minimise overall harm.

The four harms analysis is one part of the Framework for Decision Making. It makes a valuable contribution to the implementation to the Route Map[1] and the Local Protection Levels approach. More information on other elements of the Framework can be found at



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