Home is where the health is

Home is where the health is … ageing well in place.

The following is a shortened edited version of a talk given to the Edinburgh University Advanced Care Research Centre (ACRC) Spring Symposium on Monday 15th April.

Whether tenement flat, bungalow, farmhouse, or croft virtually every piece of research I have read or conversation I have held with folks over the years has articulated a desire to age in place, remain in place and to die in place – if all else is equal.

Space and place are intrinsic to not only our psychological sense of wellbeing but also to our physical health, not least in a community such as Scotland where health inequalities are so influenced by geography and economy. In the lottery of location, location, location where you live matters for how healthy you are or are not.

Over the years I have written and spoken a lot about what it means to belong to somewhere, and the influence that such a sense of place can have upon your health and wellbeing, or even more critically what happens to you when due to no fault of your own you are unable to ‘remain’ in your locale or when ‘you lose your independence.’

There is a rich history of research on the desire of people to live independently in their own homes for as long as possible. There is an accepted presumption of the truth of that sentiment, albeit that we also have growing evidence to show the clear health benefits of congregated or shared living when an individual may reach a particular age in life or stage of frailty.

The presumption of home first is part of the DNA of our social care policy and delivery. It is articulated in the Scottish Government’s post pandemic Statement of Intent on the ‘Health and Social Care of Older People.’ in the following terms:

‘Our vision for Scotland

We want people to enjoy a high quality of life as they grow older. Our ambition is to make Scotland the best place in the world to grow old. We want to achieve this through safe, integrated, person centred health and social care. Everyone should be able to live independently, and drive the decisions about their health and wellbeing; with their human rights respected and their dignity protected…’

All this underlined further when it states:

 ‘Home first approach

 People have told us that they would like their care and treatment to be delivered in their home or local community as much as possible. Our health and social care services must reorganise themselves to better support people to live well and independently in their communities as they age.’

Health and social care for older people: statement of intent – gov.scot (www.gov.scot)  (March 2021)

Laudable, clear, and factual in statement and intent. Hard to disagree with it.

And we can all recognise similar aspirations, notably the desire for independent living – throughout the years of policy of Scottish national government, whether in the seminal work of the key learning disability report ‘The Same As You?’ of 2000 which hastened further the closure of our long stay institutions, or the more recent passion behind the Feeley Report, the Independent Review of Adult Social Care (2021) – people time and time again have stated the desire to live as independently for as long as possible.

The ageing-in-place agenda posits that the preferred environment for older adults to age in is the community, where they can remain active, engaged, socially connected, and independent.

The question is – have we as a society paid more than lip service to that aspiration? Have we fostered and nurtured the civic and care capacity to respond in full to that desire or have and are the visions of ageing in place becoming rooted in the soil of delusion? How prepared is Scotland to enable people to age healthily in place?

I want to explore this issue of healthy ageing in place – through three perspectives, namely legislative, finance and the built environment.


The first is legislative. It is sometimes lost amidst all the talk of reform and reshaping, of new creation and novel development such as the National Care Service, that Scotland already has some of the most progressive health and more specifically social care legislation in the world.

The Social Care (Self-directed Support) (Scotland) Act 2013 (SDS Act) sought to bestow upon the individual who required support and care new rights guided by the principles of participation and dignity, involvement and inclusion, informed choice and collaboration. It aimed to change practice from assessing what someone needed to maintain and survive life to determining what outcomes would enable that individual to flourish and thrive. Budgets were to be in the hands of the supported person; new models of innovative, community-based supports would be developed as flexibility, creativity and diversity were written into Guidance and advice. It was all designed to allow folks to live the ordinary lives they wanted and to participate as full citizens of their local communities. In essence it was about enabling ageing in place (before the term became commonplace.) This was primary and preventative health care dovetailing into community-based social care.

Derek Feeley 8 years later in his Review told us what those of us on the ground knew already namely that the implementation of the SDS dream had failed.

It was clear from his Review that from the experience of many of the stakeholders who had engaged in its processes that the implementation of Self-directed Support (SDS) was symptomatic of the failure to embed progressive social policy within the existent political and governmental systems. SDS failed and is still failing in part because of the impacts of austerity and economic downturn and later the pandemic but in truth the faultiness are a lot more local. Social care as delivered today and Self-directed Support as initially conceived has been and is hampered and limited by the current model of local government in Scotland and by the desire to entrench power and control within the hands of those who finance and contract rather than bestow control and choice to citizens.

SDS provides the foundation stone for a re-shaping of social care that enables the person to be in control, to utilise autonomy and exercise choice not only of the decisions made around their life but of the outcomes they want to achieve.

The legislation already exists to enable place-based healthy ageing – the commitment around implementation is what is lacking. We are paying lip service to individual choice and personal control.


The second influencer upon any assessment of ageing in place must be the fiscal reality of the current moment. Folks like me who have been around this social care world for more years than we would wish to confess recognise that we have never before seen the drastic levels of savage cuts to social care provision we are facing now. What is happening in our local communities across Scotland today rides a coach and horses through legislative intent and political aspiration.

In the days and weeks that have recently passed I have come across numerous instances where individuals are having their packages of support and care reviewed, reassessed and stopped. Indeed, I know of several authorities which have established review teams ostensibly to make sure people are getting the right support but in reality to cut the majority of packages and find savings. Now in a context of fiscal waste I can understand such a measure – but we are already talking about a population who only receive services at the level of critical and emergency need. How many people do you know who as they age require less support? A few yes but the majority – no way.

Despite the self-assurance rhetoric of commissioners and local officers in health and care partnerships what we are witnessing is frankly a grotesque cost saving exercise which is putting people’s lives at risk or at best is serving to limit and diminish those lives.

Indeed, the CEO of Age Scotland Katherine Crawford warned about the precarious state of social care in Scotland, stating that:

“The longer people wait for care, the more acute their needs can become. Distressing figures from last year showed that hundreds of people died while waiting for care packages to start. For others, it is unsafe for them to be at home without the care they need, resulting in poorer health, increased hospital admissions and yet more pressure on the NHS as people are trapped in hospital.”

“The crisis in social care in Scotland is fast becoming a national scandal.

More than 10,000 people waiting for social care at home (agescotland.org.uk)

She is of course right because the latest figures from Public Health Scotland found that 6,811 people are waiting to be assessed for social care at home, with a further 3,393 waiting for a care package to be delivered. The vast majority of these are older Scots.

Because those who age in place are largely invisible, because they don’t form queues in ambulances outside hospitals or in A and E corridors – they have become the easy collateral of the phoney war which is going on in our communities. A war which proclaims a political rhetoric of more investment and funding in health and care whilst the truth on the ground is of stripped back services, packages of support being removed (often with only 72 hours’ notice) and people being quite frankly abandoned to age unhealthily. The vast majority of additional resource is helping to pay workers a better wage which is fundamental, but it is not adding to the level of support in any significant way.

We’ve turned away from an aspiration to enable people to be supported by preventative care to enable them to age in place and potentially thrive and flourish into a system which is about maintaining people. There is no dignity in a life which simply breathes in and out but whose choice, wishes, feelings, desires, and dreams are negated.


There are of course other dimensions which also need to be addressed if we are to achieve a healthy ageing in place.

Central amongst these is our built environment, not least our housing stock.

In 2018 I was writing and speaking about how important it was that we started to re-design our city centres to enable them to become once again places where people of all ages were able to call home and to do so in a manner that was truly inclusive. To some extent this has and is happening, but I fear that it is a process of re-design which excludes the potential of ageing in place. But do we have an urban environment which validates and values ageing in place?

I was intrigued by the research of three Scottish based academics Brunelli, Smith and Woolrych in a paper ‘High streets, ageing and well-being’ published in the Journal of Urban Design at the start of this year. In it they explore three Edinburgh ‘village’ high streets.

Full article: High streets, ageing and well-being (tandfonline.com)

They start from the premise that ‘despite their perceived decline, local high streets in the UK remain valuable central and well-connected places that can foster ageing in place, yet their potential to sustain well-being in old age has been overlooked.’

Analysing their qualitative and quantitative data they explore older people’s well-being in four key dimensions: social well-being, sense of place, enjoyment and feeling active and sense of purpose and mastery of the environment.

Their findings include an assertion that to make these locales more age-friendly and to support older people’s well-being:

‘it is desirable to: make the public realm more inclusive, pedestrian-friendly, and integrated with public transport infrastructure; actively support the clustering of amenities, shops, services, and bus stops, anchored to a day centre/local hub; encourage attractive shopfronts to support a welcoming and safe atmosphere including the externalization of activities, for example, adding opportunities to sit outside; and increase the provision of affordable housing near and/or on the actual high streets.’

It can be achieved with collective coherent inclusive involvement of all voices in town planning, in architectural design and in urban investment. I really do believe our cities and towns can become age friendly and dementia confident. To do so we in part need to challenge the bias in the construction industry which effectively buys out ‘social housing’ targets – when did you last see a bungalow built? We need to address the issues of pavement furniture and shared pavements; of traffic lights that are far too fast, a lack of seats and public toilets, poor visual signage and so much more.

We also need to challenge the ghettoization of ageing which creates villages for those with dementia equivalent to the asylums of the Victorian era – age out of sight out of mind even in a luxury environment. Ageing in place also requires a collective reframing of workforce skills and abilities to make all retail, commercial and community staff, both in the public and private sectors confident around age and all it brings including dementia rather than simply aware.

But as the Centre for Ageing Better made clear in a report last year:

‘ simply changing the built form is not sufficient to create a more inclusive environment for ageing since places are more than physical spaces. Viable environments are articulated through a strong sense of place, defined as the social, psychological and emotional bonds that people have with their environment. A strong sense of place results from having access to supports for active participation, opportunities to build and sustain social networks, and assuming a meaningful role in the community. In contrast a feeling of displacement or ‘placelessness’ is associated with alienation, isolation and loneliness, often resulting in adverse health and well-being outcomes, particularly amongst vulnerable older adults.’

To conclude if home is really to be where the health is, where people can age in a manner that allows them to grow and change, thrive, and flourish, then it requires the collective will of designers and architects, planner and politicians, economists, and employers to create the spaces and places that allows for that. It demands a vision of ageing where those who age are in control, not just at the centre of someone else’s concern. Technological innovation can take us part way down that road but without the societal willingness and political investment it will be a wasted journey.

Donald Macaskill

Photo by Katie Barrett on Unsplash

Last Updated on 20th April 2024 by donald.macaskill