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

In the aftermath of the Scottish Bereavement Charter Conference on the Future of Bereavement in Scotland – held a couple of days ago and which gathered a very thoughtful range of participants and a range of workshops, including the inspiring contributions of Debbie Kerslake of Birmingham – the growing intersection of AI and grieving deserves I think some wider consideration and reflection.

In my previous writing on “synthetic resurrection,” I invited readers to consider how emerging digital technologies reshape landscapes of memory and grief. At its heart, this practice asked: How might we hold the dead? And how might technology both support and challenge the dignity of that process?

Now, the News Agents piece “Would you use AI to talk to your dead relatives?” and an intriguing phone-in conversation on LBC just last week – brings that philosophical question into the everyday. It introduces Reflekta, an AI-driven service that enables families to create digital avatars of loved ones – fed by their memories, voices, and texts – and engage in ongoing conversation for a subscription fee. Some find comfort and continuity in this, especially those wishing to preserve stories (as Reflekta’s founder Greg Matusky does, using the voice of his WWII veteran father.)

Yet others, like reporter Lewis Goodall, warn of potential exploitation – cautioning that grief is not a product to be monetised, and that synthetic voices may hinder the natural process of letting go. I would tend to agree with Goodall because while Reflekta’s founder hopes to preserve family stories, there are obvious critics concerned about the ethical and emotional risks: worried that simulating a person risks substituting reality with “fiction” – a phantom that may hinder natural grieving and closure.

At this week’s bereavement conference, Debbie Kerslake joined me to explore AI and bereavement, placing technological innovation within a broader human rights and community context. She is also the Director of Brum YODO’s whose work- organising creative, communal events like A Matter of Life & Death Festival– underscores the power of shared ritual and story to process loss, foster connection, and honour forms of grief that resist digital reanimation.

Brum YODO’s ethos reminds us: talking about death, creating spaces for remembrance, imagining communal memorials- those are the foundational practices for healthy bereavement. They resist loneliness, stigma, and commodification of grief. Yet many of these accepted approaches including our own excellent Good Life, Good Death, Good Grief programme in Scotland, asks a basic yet fundamental question: Can Ai support healthy grieving?

The short answer is probably that Ai may provide narrative preservation, but cannot replace relational, embodied grieving.

The emerging scholarship on deathbots or AI-driven chatbots that emulate the presence of the deceased- so-called Interactive Personality Constructs of the Dead (IPCDs)- highlights a troubling concern: they may replicate some sense of presence but miss the profound intersubjectivity of real relationships, risking unresolved grief or emotional confusion.

For me at a very practical level at the heart of such griefbots lies a fundamental limitation: every response is based on static, past data- the recorded voice, texts, anecdotes of the person who has passed away. These AI reproductions cannot account for the reality of change – a loved one’s voice, attitudes, or advice would inevitably evolve if they were still alive- facing new world events, personal growth or even shifting relationships. They ignore the truth of personal development. Growth and wisdom occur continuously. We expect differently from those who remain with us. Ai chatbots cannot simulate these future selves of the deceased – they are frozen in time.

Thus, what such technology offers is not an evolving, relational presence, but a nostalgic snapshot- a memory preserved, not a relationship nurtured.

While Ai might help preserve memories- even offer solace in loneliness- its limitations lie in the lack of authenticity – a digital proxy cannot truly feel, respond, or evolve as the real person did. They risk dangerous dependency and overreliance on an AI persona may inhibit moving forward in a healthy way. And they also raise profound ethical concerns.

There are, also, other associated psychological risks with griefbots which the literature increasingly highlights – simulating a continuing bond may prolong the liminal state in which the deceased feels not fully gone. Grief is a process; transformation involves internalising the memory not preserving external echoes. Researchers also warn of technological “hauntings” – unsettling, unregulated presence of simulated voices that disrupt mourning and could induce emotional harm.

These AI systems often come with subscription models and algorithmic designs that reinforce emotional dependency, not healing. The bots optimise for engagement, risking manipulation of grief for profit. Monetising grief, misrepresenting the dead, and blurring lines between memory and fiction are very real risks. What happens, for instance, if your money runs out and you cannot continue the monthly subscription?  Whilst Reflekta have indicted there are use limitations and safeguards, they cannot guarantee against the risks of dependency. Such dependency may reduce the bereaved individuals’ emotional autonomy. If removing the bot means losing a vital connection, users become bound to the technology rather than free to grieve naturally.

More worryingly are the risks of anthropomorphism and what is called the ELIZA effect. This is where users inadvertently project human traits onto the chatbot, conflating simulation with sentience, which can deepen confusion and emotional reliance.  At its worst level this can be quite damaging. The well documented recent case of where a man in New York threatened to jump off a building after a recent divorce created intensive dependency upon a bot is a case in point.

So up till now I have been very negative and cautionary about the use of Ai in grief and bereavement support – but there are some, I would suggest, potential areas of use and benefit, if properly framed and boundaried.

AI might support archival storytelling – capturing memories, organising testimonials, preserving stories for future generations- but must not aim to replace the dynamic relationship or the evolving self. Such memory archives are not chat bots but rather act as the repositories of multimedia memories. There is also potential use in legacy tools and in encouraging reflection, encouraging families to remember together- without ongoing simulated interaction. But all of this has to be framed within ethical design and all practice, I would suggest has to ensure transparency, autonomy, consent, and ideally an “off button.”

AI in bereavement occupies a fragile tension between preservation and potential disruption. It can store voices and stories- but cannot embody relational depth. Communities like Good Life, Good Death, Good Grief and others remind us that grieving is not about simulation, but about shared humanity, ritual, and respect. Ai can support healthy grieving but only if held lightly, ethically, and sacrificially- subservient to the human, not the other way around. I am not at all convinced the bots we have seen and the products currently on the market are achieving that to date.

I leave you with the sage words of the great Mary Oliver, in ‘When Death Comes.’

When death comes

like the hungry bear in autumn;

when death comes and takes all the bright coins from his purse

 

to buy me, and snaps the purse shut;

when death comes

like the measle-pox

 

when death comes

like an iceberg between the shoulder blades,

 

I want to step through the door full of curiosity, wondering:

what is it going to be like, that cottage of darkness?

 

And therefore I look upon everything

as a brotherhood and a sisterhood,

and I look upon time as no more than an idea,

and I consider eternity as another possibility,

 

and I think of each life as a flower, as common

as a field daisy, and as singular,

 

and each name a comfortable music in the mouth,

tending, as all music does, toward silence,

 

and each body a lion of courage, and something

precious to the earth.

 

When it’s over, I want to say all my life

I was a bride married to amazement.

I was the bridegroom, taking the world into my arms.

 

When it’s over, I don’t want to wonder

if I have made of my life something particular, and real.

 

I don’t want to find myself sighing and frightened,

or full of argument.

 

I don’t want to end up simply having visited this world.

When Death Comes | Library of Congress

 

Donald Macaskill

Photo by Steve Johnson on Unsplash

 

This past week has felt like a bit of a transition week. For those of us who are parents of school-age children most of us will have experienced either this week or the previous one our children returning to school after what has been a surprisingly good and even traditional ‘sunny’ summer.

That first day back at school is a real rite of passage for folks – looking at the new starts all bright-faced and uncertain, and older children re-kindling friendships and contact even if mobile phones have never been out of their hands for weeks! This return to school is more than calendar – it is ritual. It marks continuity and renewal. It also reminds us of the fragility of our systems – education, care, community – that hold us together.

But in the non-school world too we are also seeing change all around us, as conkers seem to be appearing even earlier and leaves are beginning to change colour. There is a growing chill in the morning air, not yet the bite of winter, but a reminder that change marches on. The days remain long, but the evening shadows start to stretch. And as seems to be becoming pattern migratory birds are returning even earlier than normal. The seasons are turning. I have always found these in‑between times to be moments of truth-telling, and opportunities for realism.

Watching children file into school reminds us of both hope and urgency. Schools are where potential is forged; where community is invested in, where futures begin. Yet alongside this forward movement, we must remember that for many families, stability is fragile. While classrooms brim with promise, care providers – homes, charities, volunteer networks – stand on strained foundations and if we allow those foundations to crumble the edifice of health and wellbeing in our society collapses.

This season is I have always felt a time for realistic optimism, a hope for the future grounded in a realistic assessment of the present and that seasonal aptitude has never been more needed than it is now for the world of social care. And realism begins with honesty.

Over 200 charities – many providing key social care services – have come together to issue a stark warning: the care sector is not sustainable as it stands. In an Open Letter to the First Minister published last week they plead for immediate action- sufficient funding and systemic reform- to avert a collapse that would harm our most vulnerable. Their plea echoes continual statements from myself and colleagues as for months now we have warned of real and immediate risk to social care provision, and most importantly the fact that people are dying as we speak and watch, waiting for life-affirming and renewing social care support. A couple of days ago in an interview in Herald Scotland I lamented the apparent ‘paralysis of response’ from the Scottish Government. No one seems to be listening. We are deafened by the inactivity of decision-makers and the malaise of political disinterest.

The charities’ joint letter is clear: nearly half of voluntary care organisations feel financially insecure; two-thirds rely on reserves to keep going, with 91% at risk within four years if trends persist; and a full 81% of voluntary bodies report escalating financial threats to essential services. These numbers are not abstract – they are communities, relationships, and dignity dripping away. The members of Scottish Care echo the same sense of alarm and concern in the surveys we have produced over the last few months. There is an existential threat to survival within the vast majority of social care providers in Scotland.

As we turn our gaze therefore toward autumn and winter, Scotland’s social care system stands at a threshold- facing profound economic pressures and legislative shifts.

From April 2025, UK-wide Employer National Insurance Contributions (eNICs) rose significantly adding around £2.8 billion in sector-wide costs, and imposing tight margins on social care providers, particularly smaller independent and voluntary organisations operating on low fees.

But this isn’t just about finance- it’s about dignity. Providers forced to scale back, cut staff hours, or close services leave vulnerable people isolated and families without support. Realism demands we name this hardship.

Added to this – just last month, the UK government closed the adult social care visa route unless roles meet degree-level criteria- meaning many migrant care workers will no longer be eligible. New recruits must now meet higher requirements, effectively ending overseas recruitment for care work from July 2025. I had a manager in tears this past week because she was having to tell a brilliant staff member that they could not continue her visa.

These changes threaten to exacerbate existing staffing gaps. Social care leaders warn of rising attrition, especially as better-paid NHS roles lure workers away from care homes and homecare services in pursuit of stability and advancement.

The realities facing our communities and our care services are stark. The rise in costs- whether from increased employer contributions, energy bills, or the price of food- tightens the margins of already fragile services. Workforce challenges remain severe, exacerbated by changes in immigration policy that close doors for many who might have chosen Scotland as a place to live and care. Families continue to struggle with the dual responsibilities of work and caring, unpaid carers shouldering burdens often unseen.

These are not passing inconveniences. They are deep and structural. To deny them would be to engage in wishful thinking. And care, if it is to mean anything, cannot be built on illusions.

Realism demands we hold these truths without flinching. Without pretending that goodwill alone can patch the gaps. Realism demands that we have long since passed the stage where Elastoplast measures will patch up the brokenness and ensure the patient survives. Realism demands that we require brave political leadership to make decisions and choices which will result in real change and not simply spew out yet more empty rhetoric. We need hope-full realism.

So where does that leave us? In tension. Realism tells us services face cost pressures, workforce crises, and uncertain policy. Hope reminds us of emerging gains: new rights, rising pay, reform legislation, and long‑term structures that aim to embed rights and consistency.

Hopeful realism is not denial, nor is it escapism. It is choosing to act.

Hopeful realism is the art of carrying truth in one hand and courage in the other. It refuses the luxury of despair just as it rejects the comfort of denial.

Hopeful realism tells us that the narrow road is often the truest one. It asks of us not perfection, but persistence; not certainty, but commitment.

Hopeful realism is not an abstract sentiment; it is a discipline. It is the daily choosing to believe that change is possible- and the practical work of bringing it into being.

Hopeful realism is not a compromise- it is a balance.

It says: Yes, we face severe staff shortages. But we also have the capacity to train, support and properly value a new generation of carers not least if we improve terms and conditions.

It says: Yes, increased costs will strain providers. But investment and fair funding can steady the ship and that the ship is essential for all of us.

It says: Yes, immigration changes will close pathways. But with imagination and policy will, we can open new ones.

Hopeful realism is a lens that sees the cracks in the walls yet still tends the flame within.

The coming months will not be easy. Winter rarely is. But this is not a time for resignation. It is a time for choosing. Choosing to act, to support, to stand alongside. Choosing to hold our political leaders accountable to their promises. Choosing to believe that care, in its truest form, remains one of the most powerful expressions of our humanity.

The return of schools teaches us that renewal is possible. And if we can invest collectively in education- an investment in our children- surely, we can do the same in social care- an investment in our neighbours, families, elders. The spirit of educators and parents who gather at school gates each morning can be replicated by communities, policymakers, and local leaders in meeting care needs with resolve.

Yesterday I was at the Scottish Parliament and was pleased to contribute to a debate entitled ‘ Do we value social care?’ which was part of the Parliament’s annual Festival of Politics. It was a great debate and discussion, and the overall consensus of panellists and audience was no – we value the people and the outcomes of changed lives and independence, but we do not value the workforce or organisations, or even the essence of social care. That has to change if hope is not to become an illusion.

We stand at a critical juncture: buffeted by policy shifts and fiscal strain, yet buoyed by reform, rights and renewed commitment. Hopeful realism calls us neither to despair nor to distraction—but to engaged courage, to act where we can, nurture where we must, and walk together into the change that must come.

The garden is full, the hedges high- and I sense both the fullness and fragility of this moment. The sun feels generous, yet we know autumn approaches. So let this in-between time be our reminder: hope requires practice and action, and practice is hope made real and realised.

Donald Macaskill

Photo by D R on Unsplash

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