It’s been a funny old week of oscillating emotions from a day in which I spent talking about how social care has the potential to be the economic driver of our communities to the next day when I gave a speech bemoaning the fact that the social care sector was being treated like April Fools because of the gap between political rhetoric which values social care on the one hand and the palpable reality of lack of priority and investment on the other hand.

But it’s also been a week where there have been moments of inspiration – when I’ve heard of colleagues in different worlds – for instance in the clinical and acute context – share insight and challenge around different and inclusive ways of doing things – ways which treat all with respect and which are grounded in the understanding that whether in social care or health we are all linked.

And so I find myself as we move towards World Health Day and Week reflecting in this blog on what I consider to be the real promise of a whole system approach to health and social care. A promise we talk a lot about not least in Scotland but have done so little to progress.

The first mark of that promise is that it starts with a holistic understanding of health. I know after all that in the end of the day and in all the conversations, committees, consultations and discussions I am involved in – that the majority of people across Scotland are not interested in whether you come from the world of clinical health or social care – they are interested in what difference will you make to their life when they or those they love most need support and care.

A holistic understanding of health is not reduced to clinical technical input but is so much broader and dynamic. That’s why I’ve always considered the definition of health which first appeared in 1948 from the World Health Organisation to be so appealing. It stated that:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

It offered for the first time a really multidimensional view of health. But some argued that it was both too idealistic for instance a question as to whether ‘complete well-being’ was ever achievable, whilst others stated at the same time that it was too narrow and limited. So, there are more contemporary and I think holistic interpretations which I like. The one that I use most first appeared over a decade ago in the BMJ – from Huber et al:

“Health is the ability to adapt and self-manage in the face of social, physical, and emotional challenges.”

Huber et al., “How should we define health?” BMJ, 2011

That definition has I think a sense of dynamic rather than being too static. Health is not a fixed state. It is always changing. There is a focus on the person and the individual and what it takes to live well not just to meet clinical outcomes. It recognises the profundity of relationships, and the conditions we live in – and I think it is holistic in that it encompasses physical, mental, emotional, spiritual and social dimensions of well-being.

So, if that’s our starting point – the promise of a holistic grounding and understanding of health, how do the systems of clinical, acute, secondary, primary, community and social care fit into this world and how do they collectively achieve this holistic vision?

Every so often, our national imagination is stirred by talk of reforming the NHS – and we’ve seen a lot of this in the media this last week – including a new operational framework and improvement plan – and undoubtedly it will become one of the go-to themes for the election next year. We will see conferences brim with vision, thought pieces and official papers will flutter with ideas and new possibilities. Political manifestos will beat with the drum of change, however unfunded and impractical.

But every time we talk about the health of our NHS, I find myself wondering – how can you heal one part of the body while ignoring the whole ? How can you address the challenges and reap the potential of the NHS without addressing and understanding the critical role of social care?

If you stand in a care home at 7am, you’ll see care workers gently waking someone who has perhaps not spoken since Tuesday. You’ll watch someone support a man to eat who is still fighting battles he long ago forgot. If you wait long enough, you might see someone cry – not because they are sad, but because someone has finally listened to them and heard their voice. That’s health. That’s care. That’s the invisible scaffolding that holds up not only the NHS, but communities themselves.

So when we speak of reforming the NHS in Scotland, we must be honest: no amount of reorganisation, digital dashboards or apps or indeed workforce and retention tweaks, no amount of increased salaries or improved terms and conditions, will ever succeed unless we grasp the fragile threads tying it to a social care system that is unravelling.

We have, I think for too long, clung to the idea that health and social care are separate domains. Hospitals for the sick. Care homes and homecare services for the frail. GPs for diagnosis. Social workers for discharge plans. This binary thinking – and believe you me it exists in abundance even if it strikes you as overly simplistic – has created a system where people fall between the cracks – cracks that grow into canyons.

A hospital bed can be cleared by a scan and a prescription. But where does that person go next? Who helps them eat, wash, recover? Who sits with them when night falls and confusion sets in? That’s not medicine. That’s social care and compassionate response. And without it, the hospital door becomes a revolving one.

So we need not just to talk whole system approaches but to walk it.

We’ve tried integration in Scotland. On paper, at least. Integration Joint Boards (IJBs), Health and Social Care Partnerships (HSCPs), new governance models. But too often, this “integration” has been structural  – not cultural, not relational, and not felt in the daily lives of those delivering or receiving support. Too often it’s been stymied by self-interest, defensiveness and protectionism – not least around who controls the money!

We forget that integration is not about structures but about shared purpose. About valuing a care worker as much as a consultant. About giving equal dignity to a social care manager and a medical director. It is about seeing the whole person – not their diagnosis, not their discharge date, but their story.

When crises hit – Covid, ‘winter’ pressures, strikes – we turn to social care to carry the burden. We need beds? Use care homes and call it step down or interim beds. We need support? Call on care workers in the community and give some more funding for a short period to reduce the demand. And yet, when the storm passes, we return to underfunding, undervaluing, and overlooking the very system that was there for us.

If we are serious—truly serious—about NHS reform, then social care must be our first priority, not our afterthought. It must be funded sustainably. Its workforce must be respected, paid fairly, and given hope. Its leaders must be included in every major decision about health reform rather than as it is now not even being in the room. Because it is only when health and social care are integrated in vision, in leadership, and in heart, that we will build a system that truly works.

Imagine a Scotland where discharge plans begin with the question: “What matters to you?” Where care workers are not scrambling for hours and minutes but shaping lives. Where the boundaries between hospital and home, GP and guardian, nurse and neighbour are softened by collaboration, not hardened by bureaucracy.

That future isn’t impossible. But it requires bravery and humility. It requires us to stop speaking about health reform as if it ends at the hospital door. And it demands that we finally, truly, put social care at the centre of our vision for wellbeing.

Until then, any reform of the NHS is like rebuilding the roof while the foundations crumble.

Donald Macaskill

This past week I spent a couple of days in Oxford with colleagues from around the UK exploring the responsible and ethical use of Ai in social care. It was a tremendous opportunity to meet folks who I had been virtually chatting to for over a year as we all struggled to draw up a set of statements which would describe the critical role and importance of an ethical framework for the use of Ai.

I’ve described in an earlier blog the work which led to the publication on Thursday of a Guidance document on the responsible use of Ai in social care. The Guidance states that:

‘The ‘responsible use of (generative) AI in social care’ means that the use of AI systems in the care or related to the care of people supports and does not undermine, harm or unfairly breach fundamental values of care, including human rights, independence, choice and control, dignity, equality and wellbeing.’

I found the Guidance document to be immensely helpful. It is presented as a series of “I” and “we” statements in different twelve domains including choice and control, accessibility, data privacy, transparency, accountability and so on. I hope that the widespread use of this Guidance will help to ensure a growing ethical use of Ai in social care across the United Kingdom and beyond.

The group also published a Call to Action paper which frames the ongoing and continuing work which needs to be undertaken by all stakeholders. Organisations and individuals are invited to sign the statement and I would encourage you to read it.

At the event on Thursday I was personally honoured to chair a roundtable discussion on some of the ethical questions and main issues. They included an exploration of issues of privacy, of data usage and security, the challenge of addressing bias and the necessity of equity and inclusion. Indeed, as I said one of the challenges for us all is how we enable Ai to have access to data which is truly representative of all who use care and support services and all who work in them. If you are not able to share your story your voice will not be heard.

But perhaps the issue that kept coming back to my mind throughout the debates and deliberations is the issue of how Ai can be used to enhance human presence and what can be done to ensure that the increased use of Ai will not lead to the reduction in human care especially in our contemporary constrained economic circumstances. There is a very real fear that people will lose their jobs, and that the continuity of human care will be diminished. There is an anxiety that the use of Ai models and tools becomes not only more convenient but irresistible – and what does that do for both the valuing of care and its very nature? Does it even further risk embedding the myth that care is about a series of technical transactions and inputs rather than in essence a dynamic and exchange of relationship?

Indeed, I think there is a certain paradox at the heart of our digital age. As we welcome the rise of artificial intelligence into the intimate spaces of human care, we risk losing the very essence we seek to uphold: the authenticity of human connection. But I’m increasingly of a more positive view which is that if we are both wise and bold, Ai might serve not to diminish but deepen the fabric of our shared humanity.

In recent years, the narrative around Ai in social care has largely oscillated between two poles: the promise of efficiency and the fear of dehumanisation. Both are valid. But there is a third path – one that threads the ethical with the empathetic, the technical with the relational. It is here, I believe, that the true potential of Ai resides.

To understand what this might look like, we must begin not with the technology but with the individual. A person receiving care is not a passive recipient but a bearer of stories, history, culture, and identity. Ai, when framed within a human rights-based approach, can help us see the whole person – not just the task, the illness, or the need.

The work of the Oxford Institute for Ethics in AI is a beacon in this regard. Their commitment to embedding ethical principles into the architecture of Ai speaks not only to technical excellence but to moral vision. Through initiatives like the Responsible Use of Generative Ai in Social Care, and the work of its various groups such as care workers and those who use care and support services, together with the Tech Suppliers’ Pledge and the Ethical Principles Working Group, we are reminded that the design and deployment of Ai must be participatory, transparent, and accountable. It must be rooted as I’ve suggested elsewhere in the PANEL principles: Participation, Accountability, Non-discrimination, Empowerment, and Legality.

What does this mean in practice? It means involving individuals who draw on care and support, their families, and frontline workers in the very conversations that shape these technologies. It means ensuring that Ai is used not to replace human contact, but to create more time for it – to reduce administrative burdens, to surface patterns of wellbeing, to allow caregivers to be more present, more responsive, more human.

It also means vigilance. Ai is not neutral. It reflects the values and assumptions of its creators. Without careful scrutiny, it can replicate bias, entrench inequality, and obscure the voices of those most marginalised. But with principled and ethical stewardship, Ai can be a tool of liberation. It can offer us new ways to understand loneliness, to respond to distress, to design systems that are as compassionate as they are intelligent.

To embrace this potential is to reject the false dichotomy between care and code. It is to believe that technology, at its best, is a mirror held up to our deepest values. The challenge – and the invitation—is to ensure those values remain visible.

I would even go further and argue that the real potential of Ai in social care is that it can and will enable an even greater and better humanisation of care. It can and will make us better at the art of care and support, it has the potential to let us discover new and better ways of being at our most human in the exchange of care support.

Let us not be seduced by the shimmer of innovation, nor paralysed by fear. Let us be discerning, courageous, and most of all, relational. For in the end, Ai should not distance us from each other. It should draw us nearer.

And in that spirit, I leave you with lines from the Austrian poet Rainer Maria Rilke:

I Am Much Too Alone in This World, Yet Not Alone

I am much too alone in this world, yet not alone
enough
to truly consecrate the hour.
I am much too small in this world, yet not small
enough
to be to you just object and thing,
dark and smart.
I want my free will and want it accompanying
the path which leads to action;
and want during times that beg questions,
where something is up,
to be among those in the know,
or else be alone.

I want to mirror your image to its fullest perfection,
never be blind or too old
to uphold your weighty wavering reflection.
I want to unfold.
Nowhere I wish to stay crooked, bent;
for there I would be dishonest, untrue.
I want my conscience to be
true before you;
want to describe myself like a picture I observed
for a long time, one close up,
like a new word I learned and embraced,
like the everday jug,
like my mother’s face,
like a ship that carried me along
through the deadliest storm.

Quoted at https://poets.org/poem/i-am-much-too-alone-world-yet-not-alone

May our approach to Ai like good care, remain open – never blind – and always rooted in the unfolding of one another’s dignity.

Donald Macaskill

Photo by Neeqolah Creative Works on Unsplash

The other day I happened to be in conversation with an individual late in years – in fact in his nineties – who opined the view that “Happiness is for young folk – I’m just pleased to be still breathing.”

Now that may be a bit of classic Scottish cynicism, but it did get me thinking about whether happiness had a sell by date, not least at the present time when portraying faux happiness would have you run out of most social care organisations. In fact I have really pondered about whether given the week that I have just had – a week hearing stories of care home closure risk and real concern about the survival of social care in Scotland – whether because of the crazy UK Labour Government decision around Employers National Insurance or because of the crazy new regulations introduced by the Home Office around immigration – I have wondered whether or not I should even dare to write about happiness. But actually, in these challenging times I think it’s all the more important that we recognise that the value of social care is actually one which changes lives and can make people happy. That the continual failure to recognise the worth and distinctive contribution of social care and support in the lives of people is an act which itself diminishes the chance of happiness for so many people.

Why mention happiness at all, I hear you ask, well because it was the International Day of Happiness a couple of days ago on March 20th – which saw the publication  by the United Nations of the World Happiness Report. It makes for an interesting read especially in times which challenge. So, for instance it states research which shows that

‘First, people are much too pessimistic about the benevolence of others. For example, when wallets were dropped in the street by researchers, the proportion of returned wallets was far higher than people expected…

(that), benevolence increased during COVID-19 in every region of the world. People needed more help and others responded. This ‘benevolence bump’ has been sustained since then. Despite a fall from 2023 to 2024, benevolent acts are still about 10% above their pre-pandemic levels…

Benevolence also brings benefits to those doing the caring and sharing. This works best if the motivation is to help others (rather than to feel good yourself), if the act is voluntary, and if it has an obvious positive impact on the beneficiary.’

The report in its many chapters argues that the link between caring and happiness seems incontrovertible and clear and if nothing else that should validate the attractiveness of the act and profession of caring and support.

A positive statement but back to the challenge of my old friend.

For those in older age the research evidence is even clearer – being healthy requires an effort to work on your happiness levels!

We know that happiness directly enhances your mental health and wellbeing. Positive emotions have also been linked to better health outcomes and increased longevity. For instance, happier individuals tend to have stronger immune systems and lower rates of chronic illnesses. Additionally, studies have shown that positive affect contributes to longer life spans.

There are lots of things that enable such psychological and physical happiness health – and social care and support plays a massive role in this. So for instance maintaining social connections and a sense of purpose is vital for aging well. Engagement in activities such as work, volunteering, or community groups has been associated with better health and increased happiness in older adults. This active participation not only provides a sense of purpose but also fosters social interactions, both of which are essential for mental and physical well-being.

What is even more interesting is validated research that shows that older adults can experience happiness even in the presence of some cognitive decline. Research indicates that many older individuals maintain a high quality of life despite cognitive impairments, highlighting the resilience and adaptability of the aging population.

So for my old friend, happiness is not the preserve of the young, if you want to be healthy and well, in older age as in any age you need to work on it and fundamentally we know that  happiness is integral to the well-being of older adults, significantly impacting mental health, physical health, social engagement, and overall life satisfaction.

And when things are challenging or going bad, yet again we know from research evidence that it is precisely in these moments of adversity that the pursuit of happiness becomes not just desirable, but essential. Happiness is not a luxury afforded only in times of ease; it is a fundamental requirement, a necessity in the business of care, and a moral imperative in a just society. It is not just an individual task and requirement but a societal one.

When the United Nations, established their work on happiness including the day and week of happiness, it recognised that happiness is more than an individual feeling – it is a measure of collective well-being. In Scotland, where we take pride in a rights-based approach to social care, we have to consider what this means in practice especially in times when the very structures and foundations of care and support seem to be under such threat.

What it doesn’t mean is naïve escapism and an ignoring of the reality – one could argue that the intrinsic essence of happiness – which to recap is so essential for individuals and societal wellbeing at all ages – is under threat by some of the decisions we are making as a society.

The personal and individual joy and fulfilment which helps a carer to feel valued in his role, is diminished if all we do to articulate that is to utter some kind words or a clap – it requires fair pay and conditions which see care and support as an essential component of society.

The comfort of an older person knowing they will see a familiar face tomorrow, who is able to form lasting and valuable relationship and connection which dismisses isolation and loneliness, is not going to be achieved by a constant change and churn in the social care and support workforce and certainly not by a sense of being just another rotation in an overstretched workforce.

Equally the pride and professional satisfaction a care and support worker feels when they have  the time and space to build relationships, is at real risk from the obscene commissioning of rushed 5 or 15 minute visits. What does that do for anyone’s wellbeing or happiness in role?

Happiness is about purpose, about feeling that your work matters. And yet, we have allowed a system to develop where care and support workers feel invisible, exhausted, and devalued. No amount of well-intentioned rhetoric about well-being can replace the fundamental right to work with dignity.

If we are to be serious about happiness, we need to be bold enough to reimagine social care – not as a crisis to be managed, but as a space where happiness is cultivated. We need to challenge policymakers, funders, and society at large to recognise that care and support is not just about meeting basic needs but about enabling a life of dignity, fulfilment, and, yes, happiness.

For those of us working in or alongside the sector, happiness must also be about hope. Hope that we can build a better future for social care, one where staff are valued and rewarded for their vital work, where those who need support and care can access it without delay, and where the dignity and rights of every individual are upheld. This hope is not naive; it is a call to action. It is a reminder that happiness is not something we stumble upon but something we create together, through our choices, our actions, and our commitment to one another.

Because, in the end, happiness is not just about feeling good. It’s about doing that which is right and good. And there is no greater good than caring for and supporting one another.

The American poet and activist Wendell Berry in his poem, titled ‘The Peace of Wild Things,’ beautifully captures the idea of finding solace, joy, and peace even when the world feels overwhelming as it is at the moment for many of us in the world of care and support. It resonates deeply with the theme of seeking happiness amid turmoil.

The Peace of Wild Things

When despair for the world grows in me

and I wake in the night at the least sound

in fear of what my life and my children’s lives may be,

I go and lie down where the wood drake

rests in his beauty on the water, and the great heron feeds.

I come into the peace of wild things

who do not tax their lives with forethought

of grief. I come into the presence of still water.

And I feel above me the day-blind stars

waiting with their light. For a time

I rest in the grace of the world, and am free.

 

From The Peace of Wild Things by Wendell Berry – Scottish Poetry Library

 

Donald Macaskill

Photo by D Jonez on Unsplash

One thing we seem to do very well in Scotland is to produce well written legislation and policy intervention perhaps with the recent exception of the National Care Service Bill! Our problem is always in the poor implementation!

Another thing we do well is food and drink. As a nation we have a rich culinary heritage with world-class produce respected the world over. Food is woven into the very fabric of who we are.

An example of good legislation and progressive policy is the Good Food Nation Act which became law in 2022. Yet here too despite the aspiration there are very real concerns about its implementation, not least when it comes to older people – particularly those receiving care at home or in care homes.

This coming week is Nutrition and Hydration Week, with its annual focus on the criticality of both for all our health and wellbeing. For me the week and indeed the potential of the Good Food Nation Act poses some hard questions. Are we truly doing enough to ensure that every older person in Scotland, regardless of where they live, has access to nutritious, enjoyable, and culturally appropriate food? Do we see mealtimes as a moment of dignity, connection, and pleasure – or simply as another task to be ticked off? And as Scotland moves forward with the Good Food Nation Act, are we making sure that older people – who are too often invisible in food policy – are placed at the heart of the conversation?

Because let’s be honest: malnutrition and dehydration in older age are not just clinical issues. They are issues of human rights, dignity, and quality of life. Critically we too often overlook the most basic truth: good food is fundamental to good care.

For many older people in Scotland, food is a source of joy, tradition, and memory. But for too many, it has become a daily struggle.

In care homes, stretched staffing means that mealtimes can become rushed, reducing what should be a moment of social interaction to an exercise in efficiency. The challenges of chewing, swallowing, and declining appetite are not always given the attention they deserve. Too often the amount we allocate financially to the purchase of food as a State when we buy care packages is grossly inadequate. I am not at all convinced that as a society we are paying care providers an adequate amount to ensure appropriate nutrition.

For those receiving care at home, the situation can be even more precarious. Many older people in the community live alone, with limited mobility, making it harder to shop, cook, or even remember to eat and drink. Homecare workers – already pressed for time – may have only minutes to prepare a meal, leaving little opportunity for encouragement, companionship, or the careful support some people need to eat well.

And at a policy level, food and drink are too often treated as afterthoughts in social care planning rather than as core elements of wellbeing. We have guidance. We have frameworks. But what we lack is a joined-up, rights-based approach to food in care and support – one that ensures no older person is left behind when it comes to good nutrition.

Scotland’s Good Food Nation Act is a landmark piece of legislation. In the words of the quite excellent Scottish Food Coalition it is ‘ a groundbreaking piece of legislation that requires Scottish Government to think about food as an interconnected system. However, legislation alone will not create the changes we need to see.’

We see that in the failure to tie down the right to food as an explicit human right with all that entails were it to be incorporated into Scottish law. It is as the Coalition argues also critical that resource and support is given to make those on the ground achieve the aspirations of the legislation.

If the vision of the Good Food Nation Act is to become a reality, older people’s food needs must be fully recognised in every part of its implementation and that sadly to my mind is simply not happening.

This means that care homes and homecare services must be included in national and local food planning. It means social care providers must be given the resources – not just guidance – to improve food provision. It means care workers must be trained and empowered to support nutrition and hydration, recognising these as essential, not optional, parts of their role. And critically, it means that older people themselves must be heard. A Good Food Nation cannot ignore those who rely on social care.

If we are serious about tackling malnutrition and dehydration among older people in Scotland, then we need to move beyond words and into action.

We need to see better funding and training for care staff. Homecare workers, in particular, must have the time and skills to support people with eating and drinking. You cannot do that in the increasing number of commissioned 5- or 15-minute visits.

The Good Food Nation Act underlines that the right to food is a human right. But for that to be more than words it means that every older person, whether in a care home or at home, should have access to nutritious, appealing food that meets their personal and cultural needs.

Nutrition and Hydration Week is an opportunity to shine a light on these issues, but the conversation must not end here. The Good Food Nation Act gives us a once-in-a-generation chance to make food a true priority in social care.

Good food is not just about nutrients. It is about dignity, joy, and human connection. And no one – no matter their age, their health, or their circumstances – should be denied that.

As the American First Nation poet Joy Harjo says food and nutrition are not just about substance they shape our world and that is as much about older age as any age. Her poem is ‘Perhaps The World Ends Here’

The world begins at a kitchen table. No matter what, we must eat to live.

The gifts of earth are brought and prepared, set on the table. So it has been since creation, and it will go on.

We chase chickens or dogs away from it. Babies teethe at the corners. They scrape their knees under it.

It is here that children are given instructions on what it means to be human. We make men at it, we make women.

At this table we gossip, recall enemies and the ghosts of lovers.

Our dreams drink coffee with us as they put their arms around our children. They laugh with us at our poor falling-down selves and as we put ourselves back together once again at the table.

This table has been a house in the rain, an umbrella in the sun.

Wars have begun and ended at this table. It is a place to hide in the shadow of terror. A place to celebrate the terrible victory.

We have given birth on this table, and have prepared our parents for burial here.

At this table we sing with joy, with sorrow. We pray of suffering and remorse. We give thanks.

Perhaps the world will end at the kitchen table, while we are laughing and crying, eating of the last sweet bite.

From https://www.poetryfoundation.org/poems/49622/perhaps-the-world-ends-here

Donald Macaskill

Photo by Annie Spratt on Unsplash

 

Today is International Women’s Day and the theme for this annual day in 2025 is “For ALL Women and Girls: Rights. Equality. Empowerment.” It’s a theme which calls for action to unlock equal rights, power and opportunities for all and to ensure no one is left behind.

I have commented before on a number of occasions about the way in which the Scottish social care sector is dominated by the contribution and capacity of women across all ages and yet that contribution is both societally and economically devalued and unrecognised.

A day like today provides us with an opportunity both to reflect and celebrate the extraordinary contributions women have made to Scottish society as a whole but most especially in the realm of social care. It should also encourage us, I believe, to challenge the ongoing negative stereotyping and diminishing of the contribution of women and not least in social care in Scotland.

We still live in a societal and cultural context where it is assumed that the complex professional and critical role of care and support is ‘women’s work.’ Such lazy, misogynistic stereotyping enables society to devalue and diminish the essential role of care and support in our society and must be continually challenged.

I think at times we make the false assumption that things have changed and that today the majority of people in Scotland recognise that it is everybody’s responsibility regardless of gender to contribute to the care and support of all our citizens. But in truth research and surveys paint a very different picture.

A 2025 report by UN Women UK highlights that women still perform the majority of unpaid care and domestic work and constitute the majority of paid care workers in the UK. Data varies but taken together over 80% of both paid and unpaid care responsibilities are undertaken by women and girls. Indeed, in Scotland data on paid and professional care regularly a level of between 86 to 88% of staff being women.

This is not an accident of history but a reflection of deeply ingrained societal norms that have over time assigned caregiving roles to women. These norms have shaped expectations, limited opportunities, and perpetuated the idea that care is a “natural” role for women, rather than a skilled and essential profession.

These lazy stereotypes also seem to advance the opinion that care is of lesser importance and value and therefore it is ‘okay’ for women to dominate the sector. Few would articulate that sentiment openly, but it is clearly present.

We know that care is not secondary or lesser; it is the foundation upon which we build a society of compassion, dignity, and interdependence. In Scotland, social care is the backbone of our communities. It is the quiet force that enables individuals to live with dignity, families to thrive, and society to function.

And at the heart of this sector are indeed women. Women who, for generations, have stepped forward to provide care – not because it was expected of them, but because they recognised its profound value. They have been the carers in our families, the nurses in our hospitals, the support workers in our communities, and the leaders in our care organisations. Their contributions are immeasurable, yet too often, they are invisible or simply ignored.

We need to be very clear that care is not “women’s work.” Care is ‘human’ work. It is the work of compassion, empathy, and expertise. It is the work of building relationships, solving complex problems, and supporting individuals in their most vulnerable moments. To frame it as gendered is to diminish its value and to ignore the potential for all to contribute equally to this vital sector.

What we need, instead, is to challenge the assumption that care is an instinctive duty for women rather than a skilled profession, a career of choice, or a domain of leadership. We must move beyond the idea that women enter care because they are naturally more compassionate or inherently more nurturing. These are skills- honed, developed, and practised – and they deserve the same professional recognition as any other field.

So, how do we address this presumption without talking down care? How do we elevate the status of caregiving while ensuring it is seen as a role for all, not just women?

I think one of the ways we do that is to celebrate care for what it is: a profession of skill and significance. The narrative around care needs to shift from one of obligation to one of value. Care workers – the majority of whom are women – deserve recognition for the expertise they bring to their roles. Whether it is supporting someone with dementia to live well, enabling a person with disabilities to achieve independence, or providing end-of-life care with dignity, these are tasks that require training, empathy, and resilience. Let us talk about care as a career of choice, not a default.

I also think that we have to challenge the structural barriers that perpetuate the gender imbalance in social care. This means addressing the pay gap, improving working conditions, and creating pathways for career progression. It also means addressing some systemic biases within the care sector itself. For while women make up the majority of the care workforce, they are still underrepresented in decision-making roles. True equality means ensuring that women have pathways to leadership, that their voices shape policy, and that care work is seen as a space for ambition, progression, and influence.

Now on the evidence of some research which has been published this last week, we are making some progress in this regard in Scotland, but we have a considerable distance to go.

Over two decades ago I was involved in a project which was attempting to challenge the stereotype of care and gender across Europe. It recognised that things would only change if from early years or kindergarten onwards to secondary education, that we challenged the presumptions around care being female which lie at the heart of our education system. Despite continued efforts, I think we are critically short of where we need to be.

From an early age, children should be taught that caregiving is a universal responsibility, not a gendered one. Boys and girls alike should be encouraged to develop the skills of empathy, communication, and collaboration that are at the heart of care. By normalising care as a shared responsibility, we can create a future where the sector is truly inclusive.

Too often, the experiences and insights of women who care are overlooked in policy discussions and decision-making processes. Too often when we are developing economic strategies for our society, we ignore the contribution of social care as a whole and I suspect that is a subconscious gendered ignorance. Too often when we consider the importance of valuing women as entrepreneurs and as business leaders, we conveniently exclude social care from such debates and discussions failing to recognise that this is a sector which is dominated by entrepreneurial, gifted and skilled women par excellence.

This International Women’s Day, we need to honour and celebrate the women who have built, sustained, and enriched our care sector – not just as workers, but as leaders, advocates, and visionaries. But let us also commit to building a future where care is valued as it should be – as a shared responsibility, a skilled profession, and a cornerstone of a compassionate society.

Care is not women’s work. Care is everyone’s work. And it is time we all stepped up to recognise that.

 

Donald Macaskill

World Hearing Day is held on 3 March each year to raise awareness on how to prevent deafness and hearing loss and promote ear and hearing care across the world.

This year’s theme, “Changing mindsets: empower yourself to make ear and hearing care a reality for all!” emphasises how by encouraging individuals to recognise the importance of ear and hearing health, people can be inspired to change behaviour to protect their hearing from loud sounds and prevent hearing loss, check their hearing regularly, use hearing devices if needed, and support those living with hearing loss. Empowered individuals can drive change within themselves and in society at large. Part of the outputs this year is a new WHO global standard for safe listening in video game play and sports.

Anyone working in the care home or home care sector in Scotland will know just how significant the issues of hearing loss are for so many individuals who receive care and support. Indeed, according to Scottish Government data, around 850,000 people in Scotland have hearing loss, which is roughly one in six of the population; with estimates suggesting that 70% of those with hearing loss are over 70 years old. This number is projected to increase significantly in the coming years.

The very hiddenness of hearing loss is one of the many reasons why there is less societal focus on the necessary adjustments and changes which can be made to ensure that individuals are more included and involved and to ensure that those living with hearing issues are able to play their full part as citizens in their communities.

Hearing loss is not just a health condition; it is an issue which affects virtually everything about an individual’s life and how they relate to others and their sense of belonging whether in residential care or their own community. It shapes how people experience the world, how they connect, how they express themselves, and how they are included – or excluded – from society.

For too many older people, hearing impairment is a slow erosion of connection, a gradual retreat into isolation. And in a sector that prides itself on person-led, relationship-based care, this presents a fundamental challenge and one – if I am being completely honest – in the midst of other competing priorities does not receive sufficient attention.

A recent study by the British Irish Hearing Instrument Manufacturers Association (BIHIMA) found that while many older people benefit from hearing aids, 40% of those who need them do not use them effectively. Batteries go flat. Devices get lost. Staff may lack training in how to support residents with hearing aids, leading to frustration and a loss of confidence in the very technology that should empower them.

And then there are those for whom hearing aids are not the answer – people who have been Deaf since birth or who have profound hearing loss requiring British Sign Language (BSL) or other communication support. In truth the care sector across the UK has been slow to adapt to their needs, with BSL provision remaining patchy at best and little resource allocated by commissioners and funders to release staff for training and development.

Imagine living in a care home where every conversation around you is muffled, distorted, or completely inaudible. Where announcements about mealtimes or activities do not reach you. Where staff – however well-intentioned – speak too fast, do not face you, or assume you can hear because you have a hearing aid.

The result? Many older people with hearing loss become socially withdrawn. They stop participating in group activities. They disengage from conversations. They are mislabelled as confused or unresponsive, when in reality, they simply cannot hear what is being said.

And let us be very clear: hearing impairment is a risk factor for cognitive decline, depression, and even increased mortality. This is not a marginal issue – it is central to dignity, quality of life, and fundamental rights.

So, what can we do? The answer is not complicated, but it does require cultural and systemic change. It also requires yet again a targeted resource and finance that allows people to address the discrimination that happens when resources are absent.

As a society we should develop a Charter for Inclusion – and for me the primary action for deafness is staff training and awareness raising. Every care home and homecare provider should ensure staff receive training on hearing loss awareness. This includes understanding hearing aids, learning basic communication strategies (such as speaking slowly, facing the person, and reducing background noise), and being aware of the signs of undiagnosed hearing loss.

Routine hearing checks should be part of life plans for those who receive care and support services, just as vision and oral health assessments are. Care homes should have direct referral pathways to audiology services, ensuring that hearing aids are maintained and adjusted as needed.

Not all hearing loss is the same. Some people need written communication, others benefit from visual cues, and some require BSL or lip-reading support. Care providers should be proactive in tailoring communication to each individual.

We live in an era of smart hearing technology and assistive devices. From amplified telephones to captioned video calling, there are many tools that can enhance communication – if only they are made available and integrated into care and support and fiscal resource prioritised to make their purchase and use possible.

One of the greatest failings in this space is the lack of robust data on hearing loss in Scotland’s care sector. Most of the data we have is years out of date and there has been little focus to address this.

We simply do not know how many care home residents are experiencing undiagnosed hearing loss; or how many are not using their hearing aids correctly and how many care staff have had training in communication with Deaf and hard-of-hearing individuals.

This data gap is a real system and clinical, social care failure. Without accurate information, we cannot plan services, allocate resources, or advocate for the change that is so desperately needed.

If we are serious about person-led care, then hearing loss must be on the agenda. We must listen to the unheard. We must identify adequate resource and funding to ensure real inclusion.

Despite all the undoubted challenges facing it I believe it is possible for Scotland’s care sector to lead by example. To embed hearing care into the heart of what we do. To ensure that no one in a care home or receiving homecare is left in silence.

Because in the end, this is not just about hearing – it is about being heard.

The American poet Camisha L Jones reflects on the transformative impact of hearing aids, celebrating the newfound access to sounds and the emotional resonance they bring. Being heard changes your life.

 

Ode to My Hearing Aids.

 

Then God said

let there be sound

and divided the silence

wide enough for music

to be let in and it was a good groove

 

And God said

let there be overflow

sent sound in all directions

pin drops & children’s laughter

phones ringing & plates clattering

and it was kind of good but too much at times

 

So God said

let there be volume control

let there be choice how loud life should be

and there came the power to fade

the voices, the annoyances, the noise

and that was mighty good for all the unnecessary drama

 

Then God said let there be surprise, startle even

at the bird’s chirp, the ice maker,

the cabinet slammed shut

let there be delight

at the first calls in months

to father & best friend

and these were such good reasons for choking back tears

that God saw

the dark & the light

dangling brilliantly from each ear

and God whispered amen

then smiled when it was heard.

 

From Flare (Finishing Line Press, 2017). Copyright © 2017 by Camisha L. Jones. Used with the permission of the author.

 

https://poets.org/poem/ode-my-hearing-aids/print

Tuesday next (the 25^th) sees the Scottish Parliament debate and vote on the Scottish Government’s Budget. It is something of a fait accompli with the votes of the Scottish Liberal Democrats and the Green Party in the bag, and Scottish Labour sitting on its hands. Any sense of self-congratulation, however, should be short lived because not for the first time this administration has seriously let down the social care sector and the tens of thousands of women and men who rely on social care services and supports.

Yet again I find myself writing about the lack of real prioritisation being given to social care by the Scottish Government – in that, however, they are not alone – the UK Government in its new Labour iteration is doing exactly the same. In Scotland there will be defence statements made that the current administration has never given as much as it is now allocating to social care – and indeed it would be churlish not to congratulate them for continuing to finance the Scottish Living Wage which comprises the largest proportion of the additional revenue that has been given to the system this coming year. But such positivity rings hollow when the perilous reality of disintegration becomes apparent.

Social care is not a luxury. It is not an optional extra or a line item to be trimmed when budgets are tight. Social care is the foundation upon which the dignity, independence, and wellbeing of thousands of older people and individuals with disabilities rest. It is the means by which we affirm the intrinsic worth of every individual, ensuring that no one is left behind, no one is forgotten, and no one is stripped of their humanity.

Yet, the 2025 Budget tells a different story. It tells a story of missed opportunities and misplaced priorities. It tells a story of a government that has chosen to turn away from those who are most valuable, those who have contributed to society throughout their lives, and those who now depend on us to uphold their rights and dignity.

The failure to prioritise social care funding is not just an economic decision – it is a moral failing. It is a failure to recognise that the right to live with dignity, to access essential care, and to participate fully in society are not privileges to be rationed, but fundamental human rights. The United Nations Principles for Older Persons and the Convention on the Rights of Persons with Disabilities are clear: states have an obligation to ensure that older people and those with disabilities can live independently, with access to the support they need. By underfunding social care, the Scottish Government is failing to meet these obligations.

I fully recognise that government is about choices and one of the most damaging choices made by the UK Government is its decisions not to exempt social care providers (and hospices I might add) from the forthcoming increases in National Insurance rates. This is a tax on jobs and a tax on care and will drive many care organisations to the wall. It is a political madness entered into with an ignorance of consequence and a lack of compassion. Despite there being a debate on the issue again on the 25th of February in the House of Lords the Chancellor remains deaf to the desperate pleas of those who care and support tens of thousands of people and those individuals themselves.

The consequences of this political failure in both London and Edinburgh are stark. Care providers, already stretched to breaking point, are being asked to do more with less. Staff, who are the lifeblood of social care, are undervalued and underpaid, leading to chronic shortages and burnout. Older people and those who use social care services are left waiting for essential support, their lives diminished by delays and inadequacies. Families are forced to pick up the pieces, often at great personal cost.

We cannot accept this. We must demand better. We must demand a budget that reflects our values, that invests in social care as a cornerstone of a fair and just society. We must demand that the Scottish Government recognises the urgency of this crisis and takes immediate action to address it.  It might not be able to do much about a deaf Westminster, but it must do more to invest the limited resources it has available to it in social care provision. Yes, it will be hard, and decisions taken will not go down well in other sectors – but a society that does not care is not one worthy to be governed. It might even mean, heaven forfend that we invest less in the NHS and take some of the resources we have to prioritise social care over acute and secondary NHS services. Budgets are all about hard decisions – I together with thousands of others cannot accept the fiscal choice that continues to marginalise social care.

Ultimately though this is not just about money. It is about who we are as a society. It is about whether we are willing to stand up for the rights and dignity of every individual, regardless of their age or ability. It is about whether we are willing to say, with one voice, that social care matters.

The time for empty promises and half-measures is over. The time for action is now. Let us not fail those who depend on us. Let us not fail ourselves.  Let us see investment and resource reallocated and let us spend on the lives of those who remain the heart of our communities. To do otherwise is a betrayal of dignity.

Donald Macaskill

 

Photo by Christopher Bill on Unsplash

 

 

Next Thursday is the United Nation’s annual World Social Justice Day 2025. A quick look at official calendars shows that there will be lots of events around the country and across the UK on issues of gender, migration, poverty and inclusion.  But at least for me the day asks some uncomfortable questions. In Scotland we often pride ourselves on being a nation built on fairness, dignity, and equality – the very bread and butter of social justice. We are after all the nation of ‘A Man’s a man for all that.’ Yet, when it comes to social care the sector that should be at the very heart of our social justice efforts – we continue to neglect, undervalue, and overlook it.

Social care is not just about helping people live their lives with dignity; it is a profound expression of our shared humanity. It embodies the very principles of social justice: equity, human rights, and the belief that everyone, regardless of age, ability, or background, deserves to participate fully in society. Indeed, as I have said on more than one occasion the distinctive nature of social care as understood by Scottish legislation makes explicit the social justice dimension of social care. And yet, despite all the fine words and policy commitments, social care in Scotland remains on the margins, rather than at the centre, of our social justice agenda.

For me it could not be more plain social care IS social justice and social justice without social care is empty and vacuous.

Too often, social justice is discussed in abstract terms – poverty, inequality, exclusion – without recognising that social care is where these issues play out most starkly. Social care supports older people, individuals with disability, and those living with mental health conditions. It ensures that people are not trapped in their homes, isolated from their communities, or living in fear of not having their most basic needs met. It is the safety net that allows people to thrive, not just survive.

Good social care is the difference between an individual being able to choose how they live their life and having that choice stripped away. It ensures that human rights are not just a theoretical construct but a lived reality. A society that fails to invest in social care is a society that perpetuates inequality, particularly for women, disabled people, and those in poverty, who are disproportionately affected by the gaps in the system.

So why, I ask myself, despite its fundamental role in achieving social justice, does social care continue to be underfunded, undervalued, and underappreciated – at least in Scotland? Why is it that this week we have discovered again that the economic value of adult social care to the Scottish economy is £5.2 billion; that for every £1 spent there are £2 worth of additional socio-economic benefits. Social care is not a drain but a massive driver and contributor to our economy yet it hardly ever appears in any official economic strategy as such.

I suspect the primary reason for this neglect – yet the one that most would not confess to or admit – is the uncomfortable truth that social care is still seen as ‘women’s work,’ as an extension of informal family caregiving rather than a critical professional service. The chronic undervaluation of care work – both paid and unpaid – is a stark reflection of gender inequality in our society. You can also add to this the insidious ageism which pervades attitudes to social care – only this week we have witnessed the casual stereotyping of older age and the dismissal of contribution from the elderly by some political figures including a UK Minister who had been working around adult social care!

It is also not helped by the failure to accept the critical preventative role of social care but instead to continually focus on social care as a reactive response. Instead of recognising social care as a public good, policymakers and political leaders continue to treat it as an emergency response, something to be patched up rather than properly invested in. This short-termism ensures that the system lurches from one crisis to another, rather than addressing the structural inequalities that create the need for care in the first place.

At the heart of social justice is economic justice yet whilst we often speak of fair work, of paying a real living wage, of tackling in-work poverty, we refuse to see that the low pay and poor conditions in social care are an economic justice issue. Until we properly fund social care services, we will continue to condemn thousands of care workers – predominantly women – to pay that does not reflect their professionalism, insecurity, and burnout.

And over all these the classic failure to see social care as an issue of social justice is the fact that social care has become a political football rather than a political priority. Social care in Scotland has been at the centre of political debates, particularly with the proposed National Care Service. But rather than being framed as a fundamental issue of rights and justice, it has too often been reduced to a question of bureaucratic restructuring. We need to ask: will any of these reforms (even the most recent) truly shift power into the hands of those receiving care and those providing it? Or will we continue to have a system where people feel unheard, unseen, and unvalued?

If we are serious about social justice in Scotland, then social care must be our starting point. We cannot claim to be a nation committed to fairness and equality while we continue to fail those who rely on and provide care.

On World Social Justice Day, let us move beyond rhetoric. Let us commit to:

• Fair pay, conditions, and recognition for care workers rather than self-congratulation about the Living Wage and promises tomorrow.
• A human rights-based approach to care that prioritises choice, dignity, and participation and has legislative bite with a new Human Rights Act and clear implementation of social care choice not the kind that is limited by budgets.
• A shift from crisis-driven social care that is there to rescue and patch up the NHS to preventative, community-based support

Social justice is not an abstract ideal. It is something we build through action, through policy, through investment. And it starts with ensuring that no one – whether they are receiving care or providing it – is treated as disposable.

Social care is social justice. It’s time we acted like it.

I leave you with some of the poetry of the contemporary American poet Jane Hirshfield whose works are enthused with a sideways look at the essence of justice. Her poem ‘For What Binds Us’ reflects on the various forces “both physical and emotional” that connect individuals and the resilience that emerges from shared experiences and healing.

For What Binds Us

By Jane Hirshfield

There are names for what binds us:

strong forces, weak forces.

Look around, you can see them:

the skin that forms in a half-empty cup,

nails rusting into the places they join,

joints dovetailed on their own weight.

The way things stay so solidly

wherever they’ve been set down—

and gravity, scientists say, is weak.

And see how the flesh grows back

across a wound, with a great vehemence,

more strong

than the simple, untested surface before.

There’s a name for it on horses,

when it comes back darker and raised: proud flesh,

as all flesh,

is proud of its wounds, wears them

as honors given out after battle,

small triumphs pinned to the chest—

And when two people have loved each other

see how it is like a

scar between their bodies,

stronger, darker, and proud;

how the black cord makes of them a single fabric

that nothing can tear or mend.

Copyright Credit: Jane Hirshfield, “For What Binds Us” from Of Gravity & Angels. Copyright © 1988 by Jane Hirshfield and reprinted by permission of Wesleyan University Press. Source: Of Gravity & Angels (Wesleyan University Press, 1988)

This poem is available on the Poetry Foundation’s website: For What Binds Us | The Poetry Foundation

Donald Macaskill

Photo by Ian Schneider on Unsplash

There has been a great deal of talk this past week about how important it is that we support and care for individuals as close to their home as possible, including yet again an emphasis on hospital at home – as well as an increased commitment to focussing on prevention and healthcare at home from the First Minister. Yet what is often missed in the political rhetoric and proclamation is a proper understanding of what it means to support and care for someone in their own home or in a homely setting.

Some of that reality was portrayed in research which was undertaken by Scottish Care, Care Forum Wales and the Homecare Association in conjunction with Sky News and which was published this past week. It made for distressing and worrying reading and made me personally question whether we have become blinded to the need for humanity in our national response to the current social care crisis.

Entitled ‘It feels like we don’t exist’ the Sky News item explored the human cost of the social care cuts happening across the country and not least in Scotland. I’ve mentioned these cuts to care more than a few times over the last few months, but they have – unless you receive care and support or work in the sector – gone largely unnoticed and under the radar of the mainstream media. What they mean is that effectively most Health and Social Care Partnerships – the bodies who oversee and pay for the majority of care home and homecare delivery in Scotland – are having to make savage cuts of tens of millions of pounds in order to make their books balance this year and certainly into the next fiscal year. What that means – is not that there are queues outside our hospitals for our politicians and media to see – but that there are invisible impacts which mean thousands of people are having their care and support cut, or are not being assessed at all and that less and less is being spent on the support and care of some of our most valuable citizens. This is a process of cuts to life which is going largely unseen.

The Scottish Care research painted a sad and depressing insight into the reality of the current social care crisis in Scotland. Specific results from Scottish Care membership said that:

• Over 80% of respondents stated that councils have reduced the number of care packages that would previously have been awarded.
• 90% stated that councils have reduced the overall number of hours commissioned within care packages.
• Over 90% stated that councils have asked providers’ to complete care tasks that are unrealistic within the commissioned time.

Such reductions place untold stress on the sustainability of vital care providers across Scotland and diminish access to an adequate level of person-led care. As commissioning and procurement bodies cut packages beyond the true cost of adequate care for our communities, care providers are struggling to stay afloat.

A provider told me of the increasing pressure to do tick box care. One spoke of the request from a Council to support someone up out of their bed, to help them to have breakfast, to make sure they had a wash for the day and to do all this in 15 minutes! This is obscene and inhumane. Another provider spoke of the fact that their care organisation had been fined on numerous occasions because the carer had made a cup of tea or had taken out the rubbish for a supported person – all because it wasn’t in the ‘care plan’. All of this smacks of a system where money talks and compassion walks, where we have turned care and support into a functional set of tasks rather than what it should be – a relationship of dignified humanity which enables a person to flourish and thrive. Behind the rhetoric of more and more money being given to social care is the perverse truth and reality of a system of social care that should shame every Scottish citizen.

I am writing all this being very aware that when care is cut this impacts on not only the person themselves, on the workers but also the wider family who depend so much on a functioning social care system.

Tuesday next, 4^th February, is the annual World Cancer Day when we are asked to focus on the lives of those living with cancer and how we can improve health, and social care supports to enable people to live better with cancer. So often in these discussions the experience of older Scots living with cancer, and in large part supported in their own homes, goes missing from our focus.

With our ageing population more and more of those who live into older age are being diagnosed with cancer as well as the reality that positively those diagnosed younger are living longer with cancer. We often ignore the fact that older patients often present unique concerns, such as decreased tolerance to certain treatments, multiple co-existing medical conditions, and the functional challenges in daily activities which often come with age. These factors all necessitate a tailored approach to cancer care for the older citizen but in a system where we are struggling to do the basics humanely such focus and personalisation seems impossible. But it is urgent that we develop such cancer specific supports.

We know from recent research on cancer care that the role of homecare and social care is absolutely vital. Studies have shown that the benefits of home-based supportive care for advanced cancer patients is enormous. We need to resource social care to deliver more effective high quality cancer care.

What we have instead is the comments I hear from so many living with cancer, which is about rushed workers, staff constantly having to look at their watches, always on the move, and yet despite the care by the clock they are requested to make they still continue to show compassion, professionalism and care.

All our citizens, regardless of age deserve the best possible care and support in their own home or in a homely setting. This will not be achieved by ignoring the disintegration of social care across Scotland. We have to wake up to that reality and ignore the saccharine statements of assurance of a system that is working. We have to really accept that to care for someone in their own home, whether they are living with cancer or not, in a manner which affirms their rights and dignity – cannot and should never be done with a stopwatch in your hands.

Donald Macaskill