At the Global Ageing Conference in Boston, I found myself not just attending a keynote but entering a new narrative; a reframing of ageing that challenges our assumptions and invites us to imagine a different future.

Dr. Joseph Coughlin, founder of the MIT AgeLab, delivered a speech that was both intellectually rigorous and emotionally resonant. It was, in his words, “a call to rewrite the story of old age.”

I then on Wednesday had the pleasure of visiting the Age Lab and spending time with Joe and his amazing colleagues including Fullbright Scholar Elisa Cardamone from Edinburgh’s Advanced Care research Centre where I am honoured to act as Chair of the Academic Advisory Board.

Coughlin’s work has long been about exploding myths. In The Longevity Economy, he writes:

“Oldness is a social construct at odds with reality that constrains how we live after middle age—and stifles business thinking on how to best serve a group of consumers, workers, and innovators that is growing larger and wealthier with every passing day.”

This idea – that ageing is not decline but transformation – resonates deeply with my own thoughts about how our Scottish Gaelic concept of dùthchas, the sense of rootedness, belonging, and identity shapes how we care.

In Boston, Coughlin reminded us that “after age 65, society says you’re done. But in reality, you’re very likely to live another 8,000 days.” That’s a third of a lifetime. What do we do with that time? What stories do we tell?

In Scotland, we are grappling with the crisis of social care. But as I’ve argued before, crisis can be the birthplace of creativity and the spark of innovation. Coughlin’s keynote and his recent book Longevity Hubs: Regional Innovation for Global Aging offer a blueprint for renewal. He and co-author Luke Yoquinto define a longevity hub as:

“Any hotspot characterized by a disproportionate level of innovative activity aimed at the older population and related markets.”

This is not just about technology it’s about storytelling spaces. Coughlin reminded us that “story is the most powerful technology in the world.” Storytelling spaces are the places where older adults co-create solutions, where care is not delivered but designed, and where ageing is not feared but embraced. He writes:

“Emerging longevity needs encompass not only health and wealth but also social and mental well-being.”

Imagine a Longevity Hub in the Highlands. A place where dùthchas meets digital. Where crofters, carers, technologists, and artists collaborate to reimagine ageing. Where the stories of elders are not archived but activated.

One of the most compelling metaphors Coughlin offered was that of a GPS for ageing. He suggests that the traditional map of ageing is outdated, built for a world where retirement was short, predictable, and largely passive. But today, with people living decades beyond retirement age, we need a new navigation system- one that reflects the complexity, diversity, and potential of later life.

“We’ve added more life to our years, but we haven’t updated the map. We need a GPS for ageing that helps us navigate not just where we’re going, but who we want to be.”

This metaphor resonates deeply with our Scottish experience. In rural communities, where dùthchas anchors people to place and tradition, ageing is not a linear journey but rather it’s a landscape of memory, contribution, and identity. But even here, the terrain is shifting. The old waypoints and markers of retirement, dependency, institutional care, no longer suffice. We need new coordinates.

Coughlin’s GPS is not just about direction- it’s about agency. It’s about giving older adults the tools to chart their own course, to make choices, to remain connected.

“The future of ageing is not about finding a destination- it’s about designing the journey.”

This invites us to think of ageing not as a descent, but as a pilgrimage – a journey rich with possibility, shaped by relationships, values, and aspirations. In Scotland, we might say that the GPS of ageing must be calibrated to our cultural compass: one that values community, intergenerational solidarity, and the wisdom of lived experience.

Without a new GPS, we risk getting lost in outdated assumptions.

“Most of our institutions—from housing to healthcare to transportation—are still designed for a world where ageing meant withdrawal. But today’s older adults are mobile, connected, and ambitious.”

Are we designing services that help people move forward, or ones that simply manage decline? Are we offering pathways to purpose, or just places to wait?

Coughlin’s work also highlights the power of women in the longevity economy.

“Women outnumber men, control household spending and finances, and are leading the charge toward tomorrow’s creative new narrative of later life.”

This is a call to listen more deeply to the voices of older women in our communities, those who are often the backbone of informal care, community leadership, and intergenerational connection.

He also dismantles the myth of the “average senior.” Just as 25-year-olds differ widely, so do 65-year-olds.

“There’s no one-size-fits-all senior. Yet businesses often lump everyone over 60 into the same box, leading to poor products and outdated messaging.”

This insight is vital for our policy and practice in Scotland. We must design for diversity, not age. We must move beyond the dependency ratio and see older adults as contributors, creators, and citizens.

Coughlin is clear:

“Technology without empathy is just engineering.”

This is a warning and a guide. In our rush to digitise care, we must not lose sight of the human. Smart homes, wearables, and AI can enhance independence but only if they are designed with dignity, inclusion, and story in mind.

In Boston, I heard stories of older adults using tech to stay connected to grandchildren, of care homes becoming design labs, of intergenerational teams solving problems together. These are not just anecdotes- they are narrative shifts.

I return to Scotland with a renewed conviction: that the renewal of social care begins with the renewal of story. We must tell better ones. We must listen more deeply. We must design not just for longevity, but for legacy.

Let us build our own GPS for ageing. Let us honour dùthchas. Let us co-create a future where ageing is not the end of the story, but the beginning of a new chapter.

As Coughlin writes:

“The longevity economy is not just about living longer—it’s about living better, with direction, dignity, and design.”

Let us chart that course. Let us tell those stories. Let us navigate the future of ageing with courage, creativity, and care.

 

Donald Macaskill

 

The following is adapted from a speech given in Fort William on the 24th October at an event organised by Angus MacDonald MP whose primary focus was to explore his proposal to create four new 60 bed care homes in the Highlands. After reflecting on the nature of social care, its current challenging state in relation to sustainability and workforce pressures, I went on to suggest some actions which might make a difference.

So what can be done ?

Like many others we will continue to lobby for a new approach to immigration which is sensitive to demographic truth rather than political rhetoric – Scotland needs, wants and values our international colleagues, no more so than in social care – and with the pain of Brexit still felt so acutely we need the UK Government to restore a skilled workers route, or at the very least to allow Scotland to develop such a model.

It also goes without saying that we need a Budget both in Holyrood and in Westminster that properly values social care not as a nice to have but as a fundamental partner to NHS funding and provision.

But there are other things we can do which I think can help.

I want to suggest several actions:

1. A Highland Weighting Scheme.
2. Flexible models of care, including co-housing, intergenerational living, and community-led support.
3. A reformed understanding of what care home provision in remote communities needs to look like
4. Flexible regulatory and registration arrangements for workers and organisations.
5. Investment in co-ordinated digital infrastructure to support remote care delivery especially in homecare.

1.

One practical solution is the introduction of a Highland weighting– a regional pay supplement for social care workers in remote and rural areas.

Social care providers in the Highlands struggle to recruit and retain staff due to:

• Workforce availability
• Terms and conditions cf to other sectors
• Seasonal employment patterns
• Higher travel costs.

A Highland Weighting scheme would also recognise:

• The higher cost of living in rural Scotland.
• The complexity of delivering care across large distances.
• The lack of affordable social housing.

Such a scheme could be structured similarly to London’s, but tailored to rural realities:

There are some key components

• Base supplement for all care workers in designated Highland zones
• Tiered rates based on remoteness (e.g. mainland vs islands)
• Travel allowances for mobile care staff
• Housing support or relocation grants.

The London weighting scheme has shown that:

• Targeted pay supplements can improve recruitment and retention.
• Inconsistencies across sectors can cause inequality
• Transparent, annually updated models(like the Minimum Income Standard) help maintain fairness.

Applying these lessons to the Highlands would require:

• Clear criteria for eligibility
• Cross-sector coordination
• Annual review mechanisms

Other countries do this:

• Australia offers a range of financial incentives for health and social care workers in remote communities, particularly through the Remote Area Nurse Incentive Package and similar schemes for aged care and disability support.

Key Features:

• Retention bonuses and relocation grants.
• Higher base salaries in remote zones.
• Accommodation subsidies and travel allowances.
• Often tied to return-of-service obligations.

Canada – in the Northwest Territories, care workers receive a tax-free northern allowance to offset living costs and attract staff to remote communities. A similar model in the Highlands could include tiered supplements and housing support.

South Africa introduced a rural/remote allowance for social workers and other social services professionals (SSPs) working in designated remote areas. The scheme was developed using a GIS-based remoteness index to scientifically identify eligible locations.

Key Features:

• Allowance covers costs related to transport, housing, schooling, and lack of amenities.
• Aims to equalise pay between urban and rural sectors.
• Targets vacancy hotspots where recruitment is most difficult.
• Approved by the Social Development MINMEC and supported by national funding.

There are further models in Japan and nearer home in Portugal and northern Spain.

2. Community led-models of homecare.

We must also look to community-led care. We must embrace new models of homecare tailored to rural realities.

For instance, in Rannoch and Dunkeld, local trusts are developing a care-at-home service governed by the community itself. It combines paid staff and volunteers, local governance, and flexible scheduling to meet individual needs.

Again, there are clear international lessons:

Canada has adopted an Integrated Rural Home Care model

The Canadian Home Care Association (CHCA) promotes integrated care models tailored to rural needs, emphasising safety, dignity, and quality of life. Innovations include mobile care units, community-based nursing, and partnerships with Indigenous communities for culturally appropriate care.

In the United States there are many ‘At Home’ Service Models. For instance the innovative PACE (Program of All-Inclusive Care for the Elderly) combines medical and social services to help seniors stay at home safely with an emphasis on rural and remote living support – from St. John’s United (Montana) and Missouri Slope (North Dakota).

In Australia amongst many rural responses there is the IMOC Program (Innovative Models of Care trialling multidisciplinary care models in remote towns, including in NSW. There is the PRIM-HS Model in Mareeba in Queensland which is a community-led and co-designed model integrating local government, clinicians, and volunteers and aged care providers focussing on sustainable, locally tailored primary and social care for rural populations.

3.

Care homes must also evolve.

Flexible models like co-housing, intergenerational living, and small-scale community homes are being trialled in rural areas across Europe and could be adapted for rural Scotland.

We have also to be prepared to build not what is wanted and needed now but what is going to be acceptable in 10 or 20 or 30 years – and all the signs are in the UK and internationally that when people do need to move into residential care they want small, purpose built residential settings within local communities – and which are embedded, adaptable, and supported by technology.

Research by Alzheimer Scotland last year advocated for what has become known as the ‘small supports’ model – which many in the sector are only too open to deliver but which at the moment is wholly unaffordable because of the low levels of funding through the NCHC.

Indeed, Scottish Care and other stakeholders have done work on costings for a 20-25 bed care home model rather than the current model of 50 plus. But whilst it might be desirable it is wholly unaffordable within the current fiscal envelope. So key to all this change for care homes is a radically revised Cost Model within the National Care Home Contract.

4.

Flexible regulatory and registration arrangements for workers and organisations.

I am aware of the work that Jaci Douglas from the Care and Learning Alliance has been leading on in terms of the Single Care Model in the Highlands. I was pleased to meet Jaci and hear of this innovative work and I shared with her that similar models had been and are being developed and delivered in rural Canada. There several provinces maintain professional registries for early childhood educators, often linked to broader care workforce strategies. These registries support career mobility and professional recognition across child and adult care sectors.

The work of the Highland consortium is exciting, and I hope will go from strength to strength –

‘It is about taking a holistic approach in rural communities, an opportunity for people to live and work in their communities in a way that is flexible, everything needed is met i.e. person has child care which allows [her – more often women] to go to work and to care for parents or other loved ones which otherwise wouldn’t be able to.

Many carer roles are part time in smaller communities, not enough hours, this combined role would allow more full-time opportunities, this can be the difference between working and not is it worth working when not enough hours.’

To succeed it needs regulatory change and flexibility.

Australia at this very moment is actively exploring a national registration scheme for care workers that spans aged care, disability, and early childhood sectors. The so-called ACRN Proposal (2025): advocates for a nationally mandated, harmonised, and legislated registration and education scheme for all care workers. This would allow for cross-sector mobility and ensure consistent standards across community and residential care settings. Note this is not just for rural communities but it is felt by stakeholders that these communities will especially benefit.

Effectively and put simply we need to adjust our registration frameworks to enable a more flexible approach to services across the age spectrum and across sectors; and secondly we need to enable a much more flexible approach to workforce so that we get away from siloed professionalism which is not only failing us but in truth is divorced from the realities most younger workers want to experience and live in.

5.

Investment in co-ordinated digital infrastructure

The Care Technologist Project in Baillieston and other models developed by Scottish Care and now being adopted at scale in England – equip older adults with smart lighting, voice-activated devices, and robotic pets. In rural areas, such tools can reduce isolation and support independent living.

These innovations show that rural home care can be responsive, personalised, and sustainable – that is if we invest in the right infrastructure and leadership.

Conclusion

We are at a turning point.

We can continue to patch a system that is fraying. Or we can build something better- something rooted in fairness, shaped by lived experience, and responsive to local needs.

Social care is not just about services. It is about relationships, dignity, and the right to live well.

I spoke at the beginning about the sense of belonging that people like my Skye grandmother have always spoken to me about. A sense of duchlas. It is about how we care for one another, especially those who are most valuable and in need of our support. I believe we can – if we are sufficiently adventurous honour that belonging through a social care system that is compassionate, innovative, and rooted in community.

Donald Macaskill

 

Next Wednesday, 29th October, is World Stroke Day, which gives us an opportunity to reflect not only on the global burden of stroke but on its deeply personal and local impact – particularly on older people in Scotland. The theme this year, “Every Minute Counts”, is a stark reminder that stroke is a medical emergency where time lost is brain lost. It is also a call to action: to educate, to advocate, and to care.

In Scotland, stroke remains one of the leading causes of death and disability. According to a report from Public Health Scotland published a couple of months ago in 2024 alone, 11,341 people received a final diagnosis of stroke. Of these, 84.9% were ischaemic strokes, caused by a clot, and 13.8% were haemorrhagic, caused by bleeding in the brain. These numbers are not just statistics. They represent lives changed in an instant, families thrown into crisis, and communities called to respond.

The Scottish Stroke Care Audit reveals that only 52.9% of patients received the full stroke care bundle upon admission. This bundle, comprising admission to a stroke unit, swallow screening, brain imaging, and aspirin is proven to reduce mortality and improve recovery. Yet not a single health board met the national standard of 80%.

Stroke disproportionately affects older adults. The incidence rate for those over 75 is 1,382 per 100,000 population, compared to just 126 for those under 75. Recovery in older age is often complicated by frailty, comorbidities, and social isolation. The Scottish Burden of Disease report predicts a 35% increase in cerebrovascular disease by 2044, equivalent to an additional 37,000 people.

Stroke is the leading cause of disability in Scotland, and older survivors often face long-term challenges in mobility, cognition, and emotional wellbeing. The risk of stroke is 62% higher in the most deprived areas, compounding inequalities and demanding targeted community support.

Recovery from stroke is rarely linear. It is a journey marked by small victories and profound setbacks. The Stroke Association reminds us that two-thirds of stroke survivors live with long-term disabilities. Fatigue, memory loss, and emotional distress are common companions. Yet, with the right support, namely rehabilitation, peer networks, and compassionate care, many do find a new rhythm to life.

In Scotland, organisations like Chest Heart & Stroke Scotland are pioneering Health Hubs in deprived communities, offering exercise classes, health checks, and peer support. These hubs are lifelines, helping older adults rebuild not just their bodies but their confidence and connections.

While acute stroke care often begins in hospital, long-term recovery is sustained in the community and this is where social care services become indispensable.

Care homes in Scotland are increasingly recognised as rehabilitation environments, not just places of residence. They can offer 24/7 clinical supervision, ensuring continuity of care and immediate response to complications. They also enable multidisciplinary coordination, with physiotherapists, occupational therapists, nurses, and care staff working together to support recovery goals. And critically they can foster social engagement, which combats isolation and apathy – two major barriers to stroke recovery.

In care homes, stroke survivors benefit from structured therapy programmes that are difficult to replicate at home. Group activities, peer support, and routine all contribute to improved outcomes in mobility, self-care, and emotional wellbeing.

For many older adults, home care services offer the chance to recover in a familiar environment. Scotland’s Intermediate Care Teams, including Early Supported Discharge and Reablement services bridge the gap between hospital and home. These teams can deliver stroke-specific rehabilitation at home, often at hospital-level intensity. They can also provide short-term support to relearn daily living skills and regain independence

However, home care is not without challenges. Space limitations, lack of equipment, and reduced therapy intensity can hinder recovery. That’s why integrated care planning, involving families, carers, and professionals – is essential.

As we look to the future, we must ask: are we investing enough in the social care and in its workforce in relation to stroke recovery? Are we recognising the expertise of care home staff and home carers in stroke recovery?

The economic cost of stroke in Scotland is projected to exceed £2.5 billion annually by 2025, rising to £4.5 billion by 2035. Much of this burden falls on social care. Yet, the sector remains underfunded and undervalued.

We need a national conversation about the role of social care in stroke recovery. We need to celebrate its contribution, support its workforce, and embed it fully in our stroke strategy.

To close, I offer a poem by Hannah Lowe, whose work in Magma Poetry captures the quiet devastation and enduring love that stroke brings into a family:

The Stroke

For days after the stroke, she laid bed-bound, misdiagnosed –

the Doctor said ‘Bells Palsy’ of her weeping eye and tilted frown,

her hand cold-numb below the eiderdown…

Her body was a blueprint, harbinger of duty, worry, pain…

And still my mother didn’t answer.

These lines remind us that stroke is not just a clinical event – it is a deeply human one. It touches memory, identity, and relationship. And it calls us, as a society, to respond with empathy, urgency, and hope.

Donald Macaskill

Today, October 18, is World Menopause Day.

When I was growing up, menopause was a word rarely spoken aloud. It was cloaked in euphemism and silence, even in health and care settings. Thankfully, in recent years, that silence has begun to lift. Thanks to the advocacy of women like Davina McCall and countless others, menopause is now part of our public discourse.

But awareness is only the beginning.

Menopause is not simply a biological milestone. It is a deeply personal transition, one that touches identity, dignity, and wellbeing. For many, it is a time of hot flushes and sleepless nights, but also of anxiety, loss of confidence, and changes in cognition and memory. It can be a time of liberation, but also of stigma and invisibility.

And in the world of ageing and social care, menopause is not something left behind in middle age. Its effects ripple forward into later life. Bone health, cardiovascular disease, mental wellbeing, and cognitive function – all are shaped by the hormonal shifts of menopause.

Recent research has shown that menopause, particularly the transition phase, is associated with accelerated biological ageing across multiple organ systems, with liver, metabolic, and kidney health most affected. Earlier menopause is linked to increased risks of osteoporosis, dementia, and heart disease.

This means that in our care homes, in our communities, and through our homecare services, we are supporting women who live with the long-term consequences of menopause. Yet too often, their discomforts are dismissed as “just age.” Their histories go unacknowledged. Their symptoms – urinary issues, sexual health concerns, mood changes – are rarely validated.

A truly rights-based approach to care demands that we take women’s health across the life course seriously – from puberty to post-menopause.

But menopause is not only about those we care for. It is also about those who care.

The majority of Scotland’s social care workforce are women. Many are in their 40s and 50s – precisely the ages when menopausal change is most present. The demands of care work are physical and emotional. Night shifts, lifting, relentless schedules. Add to this the brain fog, the sweats, the fatigue, the anxiety of menopause, and you begin to see why staff support is not a luxury – it is a necessity.

Recent guidance from Skills for Care reveals that 77% of women experience menopausal symptoms, with nearly a quarter reporting them as severe. 44% say their ability to work is affected. One in ten have considered leaving their job due to menopause. These are not statistics. These are stories of women who give so much compassion to others yet often receive little in return.

If we value care, we must value carers. That means creating workplaces where menopause is not whispered about but understood. Where adjustments are made. Where compassion is shown. Where women feel safe to speak, and managers are equipped to listen.

Menopause is not a footnote in the story of ageing. It is a chapter of transformation. And in a Scotland that values human rights, care, and compassion, it is a chapter we must no longer ignore.

World Menopause Day is more than awareness. It is a call for cultural change. A call to honour the contribution of women across the life course. A call to ensure that healthcare, social care, and workplaces are aligned in recognising the impact of menopause and offering practical, humane support.

This is not marginal. It is central.

To ignore menopause is to ignore the lives of millions of women – our mothers, our colleagues, our carers, our friends. Let us listen. Let us learn. Let us lead with empathy.

I leave you with a poem, shared by menopause advocate Tass Smith, which captures the emotional truth of menopause in a way that clinical language cannot. It speaks to the unpredictability, the loss of confidence, and the haunting repetition of symptoms that many women experiences. It is a reminder that menopause is not just a medical condition – it is a lived reality, and one that deserves to be seen, heard, and supported.

She Loves Me, She Loves Me Not

She loves me.

By day she sits, quietly, by my side.

My night cool and restful.

She loves me not.

She laughs mockingly in my face.

And it burns.

The fog descends, and with it, my capacity to think.

I’m a rabbit caught in the headlights.

I stumble, blindly through the day, tears pricking my eyes.

She’s packed away my self-esteem.

My courage fails me.

Meltdown.

The night brings no solace.

Her furnace stoked.

I lie awake, haunted by the nightmare of my day’s ineptitude.

I’m stuck on repeat.

Oh she tells me it’s just my age; a phase to go through.

That my hormones will, eventually, settle down.

Bring on that day.

 

Taken from https://lifenow.uk/blog/the-raw-truth-of-menopause

 

Donald Macaskill

Each October, Baby Loss Awareness Week asks us to pause and acknowledge the grief of parents whose children have died in pregnancy, at birth, or in infancy. It is a week held in absent silence, in candlelight vigils, in the whispered sharing of pain that is so often hidden.

Too often, when we speak of baby loss, we imagine it only as a contemporary grief. We think of the mother in her twenties or thirties, or of parents newly navigating the impossible path of loss. Yet there is another story, less often spoken. It is the story of those who experienced the death of their baby decades ago, who are now older, and who still carry that grief in ways that are both visible and unseen.

Over the years I have had the privilege of sitting with older people in care homes, in hospices, and in the quiet of their own homes. Many have told me stories that had lain untold for years. Some have spoken for the first time of the child they lost as a young woman or man – sometimes through miscarriage in an era when such things were cloaked in silence, sometimes through stillbirth when no photograph, no name, no ritual of farewell was encouraged or permitted.

The grief of baby loss is unlike any other. It is the shattering of expectation, the fracture of future. For older people, the weight of this grief has often been borne in silence. In previous generations, the language of loss was denied them; they were told to “move on,” to have another child, to “forget.” But grief does not forget. It embeds itself in memory, in anniversaries, in the way a mother looks at her grown children and quietly counts the one who is missing.

For many older people, there was little space to acknowledge loss. Hospital practices of the 1950s, 60s, and 70s often denied parents the chance to hold their baby, to name them, to bury them. The cultural silence of the time compounded the wound. The result is that many live today with an unspoken grief that has stretched across the decades.

I recall one woman in her eighties telling me, with tears on her cheeks, about the stillborn daughter she had in 1961. It was the first time she had ever spoken of her child outside her family. “I wasn’t allowed to see her,” she told me. “I wasn’t allowed to grieve.” Half a century later, the pain was as fresh as if it had happened yesterday.

Baby Loss Awareness Week should be for her too – and for the many like her whose sorrow has not diminished with time but has simply been carried.

There is something uniquely cruel in losing a baby. Unlike other bereavements, it is not only the present you mourn, but the entirety of a future denied. Older people often carry a double grief – not just for the baby they lost, but for the adult that child might have become, for the grandchildren they might have known, for the family stories never written.

In the long arc of life, that absence remains a presence. It shapes birthdays, family gatherings, even moments of joy. Many older people find that as they age, as memory sharpens around the edges of their life story, the loss of a baby comes back into sharper focus. What was buried in silence emerges again, demanding acknowledgement.

For those of us who support older people – whether as carers, nurses, family or friends – there is a responsibility to listen to these stories when they are offered. Bearing witness to long-buried grief is an act of dignity. It says: your child mattered; your love is not forgotten; your story deserves space.

Care as we know well is not only about attending to the body. It is about holding the soul in its fragility, recognising that the person before us is shaped by every joy and every sorrow they have carried. Baby Loss Awareness Week calls us to remember that grief does not age out. It does not fade with time. It remains part of the fabric of who someone is.

If we are to be a society that truly cares, we must do more to recognise the historic grief of baby loss among older people. Bereavement support today has improved enormously compared to the past, but many who experienced loss in earlier decades were denied the rituals, the recognition, and the care that parents now rightly expect. I know about and am in awe of the absolutely amazing work of “Held in our Hearts“ and can only imagine the immense support that older people could have received had such an organisation existed decades ago.

Health and social care professionals need to be alert to the presence of this long shadow of grief. Care planning, life-story work, and spiritual support should all create space for people to share these experiences if they wish. Training in bereavement care for those who work with older people must include awareness of historic baby loss.

At a policy level, baby loss strategies should explicitly acknowledge that remembrance is not time-limited. Services and charities working in this field should consider outreach to older people, enabling them to name, remember, and commemorate their children in ways they were once denied. Public rituals, memorial spaces, and acts of collective remembrance should be inclusive of all generations, not just the newly bereaved.

Recognition will not erase the loss, but it can bring comfort, healing, and dignity. It can help older people feel that their children are no longer forgotten, and that their grief is no longer borne in silence.

For many older people, remembrance is not a burden but a necessity. To remember their baby is to acknowledge that their child lived, however briefly, and that their love endures.

In marking the losses of older parents who grieve their children decades on, I am reminded of the words of Christina Rossetti in her poem Remember (1862). Though written in another age, her words capture both the longing for remembrance and the acceptance that love endures, even when speech is silenced:

Remember

Christina Rossetti

 

Remember me when I am gone away,

Gone far away into the silent land;

When you can no more hold me by the hand,

Nor I half turn to go yet turning stay.

 

Remember me when no more day by day

You tell me of our future that you planned:

Only remember me; you understand

It will be late to counsel then or pray.

 

Yet if you should forget me for a while

And afterwards remember, do not grieve:

For if the darkness and corruption leave

A vestige of the thoughts that once I had,

Better by far you should forget and smile

Than that you should remember and be sad.

 

Donald Macaskill

 

Photo by The Good Funeral Guide on Unsplash

The following is based on an opening address given a couple of weeks ago at the Westminster Policy Conference.

We meet in autumn. The air is a lot sharper. The green has given away to the gold. We are between the light and the dark, between summer and winter.

And that is exactly where social care in Scotland is today – in-between. Between aspiration and exhaustion. Between rhetoric and reality. Between what is, and what could be.

So, I want to begin not with statistics, nor even with strategy, but with a story.

A few weeks ago, I sat with a woman in the northwest of Scotland. She is 87. She told me, with tears in her eyes, that her greatest wish is to remain in her croft – the home where her children grew up, where her husband died, where her garden still bursts with colour every spring and Highland summer. But she fears she will not be able to, because she cannot get the hours of support she needs.

Her words and her eyes have stayed with me: “I do not want to be a burden. I want to be myself. I want to live my life, not someone else’s.”

And in that single sentence lies the heart of social care in Scotland. It is not about structures, or even services. It is about life, dignity, being able to live as oneself.

Let’s be honest: the system is groaning under pressure. I hear daily from providers who tell me they do not know if they can last the year. I hear from staff who love their jobs but are leaving because love does not pay the mortgage.

I remember a care worker in Fife who said to me, “Donald, I have two jobs. I leave the care home after a 12-hour shift and go to clean offices, because otherwise I cannot keep up with my bills.”

What does it say about us as a nation when someone who does the most human, the most intimate of tasks – helping someone dress, helping them eat, holding their hand in the night when they are afraid – must then scrub toilets in order to survive?

These are not isolated stories. They are Scotland in 2025. I have this past week travelled top Aberdeen, Dundee, Edinburgh and Glasgow and I am hearing the same thing everywhere.

Providers tell me they may not survive. Half are financially insecure. Staff are weary; families are breaking.

Add to this the ending of the adult social care visa route in July. In Skye, in Barrhead, in Lanarkshire, managers have told me they rely on workers from the Philippines, from Ghana, from India – people who have become neighbours, friends, part of the fabric of our communities. Removing that route is like pulling out a thread from a tapestry – and the whole pattern begins to unravel.

And it is unravelling before our eyes. I spoke to a care home manager a couple of weeks ago who has 80% of her staff on international visas – and she is now beginning the process of having to tell too many of them that their visas will not be continued.

What is happening in that remote community? It’s not just the loss of a worker but the prospect of losing a care home in the midst of community; the prospect of the care workers’s children who’ve kept the local village school abundant in life having to leave and her husband too – yet again another skilled individual lost to a remote community.

And all the time decisions are made in distant detached realities deaf to the heartbeat of community in Scotland.

Realism tells us that social care is at breaking point.

But despite my virtual daily phone calls with somebody at the other end in tears at the collapsing of social care in Scotland – I hold onto hopeful realism, because alongside the exhaustion I also meet extraordinary resilience.

In a care home in Ayr, I saw a young care assistant sitting beside a man with dementia, singing quietly to him a tàladh – a Gaelic lullaby – the lullaby her grandmother used to sing. His agitation eased, his eyes softened. There was connection, comfort, love. Hope broke in.

That is the hope we must build upon.

When politicians speak of reform, they often use the language of systems and structures. They talk of Bills and frameworks, of services and silos. Of consultations and advisory boards.

And yes, those things matter. But reform is not simply about moving the pieces of the jigsaw. It is about painting a new picture altogether.

I remember a young man with a learning disability in Glasgow when I ran a project there a couple of decades ago. He told me he wanted to work with computers. Instead, he was offered a place at a day centre where he could do jigsaws. “It’s not that I don’t like jigsaws,” he said, “but I want to do more than pass time. I want to live a life.”

That, for me, is what reform must be about – moving from passing time to living life; moving from a maintenance approach to social care which keeps people as they are safe yet contained, a fulfilling our statutory duty approach – to enabling people to flourish and thrive not just exist; to empower people to be citizens so that they’re belonging interrupts and disrupts all our lives in a positive way.

Reform must not mean rearranging the furniture. It must mean a new way of living.

Reform means:

• Rights lived, not rights listed. Not a human rights logo on a government website, but the daily reality of autonomy, dignity, participation. Not saying to someone that because it costs more to support you to be independent in your own home that you have no choice but to go into residential care.
• Person-led, not person-fitted. Too many of our services still require people to fit into their shape. Real reform turns that on its head. Real reform enables us to have a creativity which redesigns the present structures and models of care support into what people increasingly demand, want and deserve but which they cannot get because it’s existence is budgeted out of possibility.
• Co-production, not consultation. Sitting with people before the decision, not after. Let’s end the game of pretence which uses language like co-design to suggest participation – when the reality is a predetermined set of responses massaged into apparent engagement.
• Fair work. And here I want to be blunt: we are failing the predominantly female workforce of social care. Eight out of ten are women, yet their pay lags behind, their careers are undervalued, their pensions insecure. This is gender injustice written into the fabric of our system. In a week where the latest data from SSSC the workforce regulator shows that 1 in 12 working Scots is in social care – this is a lamentable state of affairs.

Reform must not only be structural — it must be moral.

As the poet Hugh MacDiarmid once cried:

“Scotland small? Our multiform, our infinite Scotland small?”

In the same way, I ask: will our vision of care and support be small, mean, and miserly? A reform and change limited by an imprisonment of affordability and reality rather than aspiration and reimagining.

Or will our reform be infinite – rooted in rights, generous in scope, brave in ambition?

I have sat in more strategy rooms than I can count. I have seen policy papers crafted with elegant words. I have listened to Ministers make soaring speeches. And yet I have also seen how easily these things falter when they meet the ground.

Implementation is not glamorous. It is hard work. It is messy. It requires compromise.

A few months ago, a small provider told me: “we have survived not because of government but despite it. We’ve survived because local people care, because staff go the extra mile, because families muck in.”

That is both inspiring and damning. Inspiring because of the resilience of communities. Damning because we cannot build a system on heroic endurance. Heroism is not a policy. Endurance is not a strategy

Implementation is where aspiration meets accountancy.

We need implementation that is resourced, supported, and intentional.

Implementation requires:

• Clarity of purpose – never losing sight of the why.
• Proper funding – not dreams without legs.
• Local flexibility – Shetland is not Glasgow and must not be treated as such.
• Leadership at every level – not just in Holyrood but in homes, communities, and among people who use services themselves.

Every act of care, every local innovation, every moment of dignity matters – but only if the system enables them.

Let me put it in five imperatives:

1. Rights into reality. Every commissioning decision must be tested against human rights.
2. Workforce justice. Pay parity, pensions, progression. Without staff, there is no system.
3. Real co-production. Stop tokenism. Share power.
4. Rebalancing spend. Move money from crisis health treatment into preventative care and community support. A billion shifted from the NHS budget is not theft – it is investment in sustainability.
5. Changing the story. We must stop talking of social care as a cost. It is not a burden – it is a blessing, an asset, the foundation of citizenship.

I want to finish as I started with a story.

I was in a care home earlier this year. An elderly gentleman with advanced dementia was nearing the end of his life. His daughter sat by his bedside, holding his hand. She said to me quietly, “I know my father does not know me now. But I know him. And that is enough. What I need is the time, the space, and the support to sit with him, to be with him, to say goodbye well.”

That is what social care gives us – the possibility of a good life, and the possibility of a good death.

Or, as the Gaelic proverb has it: “Is e cairt nan daoine an saoghal” – “The world is carried on people.” Social care is that carrying.

Hopeful realism tells us that our system is near collapse – but also that collapse is not inevitable. If we choose differently, if we invest, if we reform, if we implement with urgency and with humanity, then we can still build a Scotland where every daughter can sit with her father without fear, where every older woman can stay in her home, where every young man with a disability can live the life he dreams of.

That is the Scotland I believe in. That is the Scotland we must fight for together.

But all that aspiration requires political leadership that does not just use words to hide inaction but governs with urgency and with focus. We are distinctly lacking such. After a summer of relative inactivity on the part of Scottish Government in the face of a social care crisis we are now into an autumn of silent inaction, where women and men are dying waiting for care as assessments now take months, as care home beds are cut and as care at home packages are being reduced and removed.

Social care does indeed carry people, but it urgently needs political and societal leadership to share the burden rather than walk away. And the need is urgent.

Donald Macaskill

Just occasionally in a conversation or an exchange you hear a word, and it sparks imagination or memory. I was fortunate and have been now for a few weeks to be listening to the Ctrl + Care podcast – which I can thoroughly recommend – and during one of them one of the two main contributors, Michelle Corrigan spoke about how social care is about discernment and how Ai for instance can never replace the activity and the art of discernment.

I have to confess it’s not a word I have used or reflected on for a long period and certainly not outside what might be spiritual or ecclesiastical corridors but Michelle in using it made me think just what is the role of discernment in social care and I reflected further on this at a conference on social care nursing just the other day. So here are some thoughts.

At first the word discernment sounds like an ancient word – something belonging more to the monastery than the modern care home, more to cloistered silence than the daily demands of home care visits. But I want to suggest that discernment is actually at the very heart of what it means to care and support another. And indeed, it is at the very heart of the distinctiveness of social care nursing.

The word comes from the Latin discernere – to separate, to distinguish, to sift. It is more than decision-making, more than problem-solving. It is attentiveness. It is about listening deeply, weighing not just facts but feelings, not just rules but realities.

It is not simply about seeing but about perceiving, about teasing out what is important from what is secondary, what is of value from what is distraction. In the Christian mystical tradition, discernment was spoken of as the ability to sense where love and life were moving, to detect the whisper of the Spirit amidst the noise of daily routine.

In the ancient traditions, discernment was a virtue. In the Celtic world of this land, it was often linked with the idea of anam cara – the soul friend – the one who helps another see the truth of their life. In the secular and philosophical traditions, discernment was seen as a discipline of wisdom: the slow and patient art of sifting, of waiting for clarity before action.

And I think social care nursing, in its essence, is this: not only the application of knowledge and skill, but the cultivation of soul-friendship, the gift of discernment.

In our care homes and in our homecare services, discernment is what distinguishes a task-driven approach from a relationship-centred practice.

It is the difference between hearing a request for a cup of tea – and recognising the deeper thirst for companionship that lies behind it.

It is the knowledge that when someone living with dementia refuses their medication, it may not be stubbornness – but fear, confusion, or a memory of trauma.

It is the sense that when a resident is restless in the night, the issue is not simply sleeplessness – but someone in need of comfort.

Discernment is what guides a carer to pause for a moment longer at a bedside, to ask the question that was nearly left unasked, to offer dignity in the small acts of attention.

Social care nursing has always been about this art: the art of listening beyond the words, the art of noticing the unspoken. And it is so because it is profoundly about nurturing relationship which is always more than simply performing a task.

John O’Donohue, in his luminous book Anam Cara, writes:

“The heart of discernment is to listen for the presence of the other. When you listen generously to people, they can hear the truth in themselves, often for the first time.”

That is, I suspect, the gift of social care nursing. It is not only about providing treatment or attending to tasks, but about creating the kind of space where someone can rediscover themselves, where their own truth can surface.

We are not technicians of the body alone. We are companions of the soul.

Discernment, in this way, is not a luxury. It is not an added extra. It is the very texture of good care and support. It is what makes social care nursing distinctive – grounded in skill, yes, but rooted in presence, in patience, and in the kind of listening that allows another to become more fully themselves.

The art of discernment in social care and social care nursing is one which I think needs to be rediscovered.

And perhaps today, more than ever, discernment is an act of resistance.

It resists the reduction of care to cost.

It resists the temptation to make relationship secondary to efficiency.

It resists the belief that rules and procedures can ever replace the lived moment of encounter.

Discernment insists that every decision is contextual, every encounter is unique, and every person is worthy of time and thought.

We have not lost this need today. Indeed, in a world of information overload, where care is often reduced to metrics and measures, discernment calls us back to something deeper. It asks us to resist rushing, to question the easy answer, to attend to the fragile humanity in front of us.

This is the distinctiveness of social care nursing. It is not simply about doing for another. It is about being with another. It is about the ancient art of wisdom rooted in the everyday acts of attention.

This is not to dismiss the necessity of policy, procedure, or system. But discernment reminds us that no rulebook can ever replace the lived moment of care, the eye contact, the listening ear, the intuitive sense of what is right in this unique situation.

So let me close with a poem, offered as a meditation, echoing the Celtic soul-tone that John O’Donohue so often gifted us:

 

In the stillness between sea and stone,

where the wind carries whispers of ancient hills,

discernment walks softly,

like a pilgrim listening for the soul of the land.

 

It is the knowing of tide from wave,

the hearing of truth in the hush of a pause,

the sight of light breaking through cloud,

revealing what lies hidden, tender, and true.

 

To discern is to sit by the hearth of another’s being,

to hear the music beneath their silence,

to cradle their story as one cradles flame,

protecting it from the gust of indifference.

 

And in this gentle seeing,

this soul-friendship born of presence,

we remember that care is not duty alone,

but the ancient art of belonging,

the blessing of one heart recognising another.

 

Donald Macaskill