Not for the first time and I suspect not the last – I found myself standing in an airport bookshop a few weeks ago – looking at the array of books to entice the traveller to summer reading. I was struck as I always have been by just how many books there are out there on leadership and management – indeed it is a theme I have spoken and written about a fair deal in the past. This year, however, one word seemed to be commonplace both on the covers and inside some of these books and that is ‘courage’ or ‘courageous’. Everywhere I looked there seemed to be work on courageous leadership. It started me off on a spell of reflection and consideration as to what if anything such concepts might mean for or speak to social care in Scotland at this time.

One online definition from Google – much changed by Ai this past week- told me that:

‘Courageous leadership is a concept in leadership thought that emphasises the moral and ethical bravery required to lead with integrity, especially in the face of risk, uncertainty, or opposition. The main aspects include, moral courage, authenticity, resilience, an empowerment of others and long-term vision over short-term gain:’

Not much to disagree with there and indeed concepts of courage in leadership are age old even if books on the theme only started to appear with volume in the 1990s onwards.

But what does the recent resurgence of the idea of ‘courageous leadership’ have to say to social care and Scotland today?

We are certainly living in days of fragility and uncertainty. Every other day I get an email from someone either working in or providing services which raises concerns about the state of the sector and a sense of despair that no-one seems to be doing anything about it, except talking.

Indeed this past week I got an email from colleagues at Alzheimer Scotland which highlighted that their own ‘Stop the Cuts’ online campaign and petition had reached 10,000 signatories – a campaign which I would commend to you and which is seeking to draw attention to the withdrawal of critical support and care from thousands of individuals across the country – all of it happening out of sight and out of mind – as a result of savage cuts to budgets.

And yet in these days of intense uncertainty, when so much feels fragile, it is easy to lose ourselves in the immediacy of crisis and miss the deeper task that lies before us. That task, in Scotland today, is I believe first and foremost to ensure that older people are not only cared for, but valued, cherished, and enabled to flourish. Achieving this will demand not just competence, not just vision, but courageous leadership – in our politics, in our social care, and in the communities where older people live their lives.

Brené Brown, in one of the better recent books on courage in leadership, Dare to Lead, reminds us that:

“The courage to be vulnerable is not about winning or losing, it’s about the courage to show up when you can’t predict or control the outcome.”

That, I would argue, is precisely the challenge facing leaders in Scotland today. We cannot predict the future of social care funding, of demographic change, of the pressures on health and wellbeing. But we can – and must – show up with honesty, humility, and bravery. The problem all too often is a denial of truth, a willingness to take the easy route and arrogance of false assurance.

Too often, our discourse around older people drifts into deficit: cost, dependency, burden. This is not only morally wrong, but also socially and economically short‑sighted.

Courageous leadership, then, is the willingness to confront the uncomfortable truths: that our current systems are not adequate; that too many older Scots live with loneliness, poverty, or untreated ill‑health; and that tinkering at the edges will not suffice.

How you move from the inadequacy of the here and now to a future orientation is what matters and simply more of the same will not do the job. Something political leadership needs to be hearing as we move towards an election next year. Because courageous leadership in social care requires political bravery rather than tramline party conformity. It means telling hard truths about taxation and public spending. It means resisting the seduction of short-term fixes in favour of long-term transformation. Olaf Groth, writing in The Great Remobilization, warns that leaders in our time cannot simply manage disruption – they must anticipate and re design for it. Scotland’s ageing population is not a looming crisis to be feared, but a predictable reality to be planned for with creativity, compassion, and courage.

Another writer I have come across, Kirstin Ferguson, in her recent work Head & Heart: The Art of Modern Leadership, calls on leaders to bring both rational clarity and deep empathy to their roles. This balance is essential in social care. We must be analytical about budgets, workforce planning, and integration with health services – but we must also be profoundly human, listening to older people’s voices, respecting their dignity, and recognising their aspirations.

I often say that leadership in social care is not about heroic acts, but about everyday bravery. The carer who chooses to stay an extra 15 minutes with someone who is lonely. The manager who challenges unfairness even when it risks unpopularity. The politician who argues for investment in prevention, knowing the electoral rewards may be minimal. These are acts of what Brown calls “whole‑hearted leadership.”

But let us be clear: the stakes could not be higher. If we lack courage, we will condemn too many older Scots to lives of diminished wellbeing. If we embrace it, we have the chance to create a Scotland where older people not only live longer, but live better – where health, dignity, and purpose are not privileges, but rights.

We cannot avoid the realities of ageing. We cannot skirt around the inadequacies of current provision. We must go through – with vision, with honesty, with courage. And in doing so, we may yet build a Scotland where ageing is not feared but celebrated, and where courageous leadership makes older people’s wellbeing a cornerstone of our shared future.

 

As the great contemporary Nigerian born poet Niyi Osundare writes in ‘The Leader and the Led.’:

 

The Lion stakes his claim

To the leadership of the pack

 

But the Antelopes remember

The ferocious pounce of his paws

 

The hyena says the crown is made for him

But the Impalas shudder at his lethal appetite

 

The Giraffe craves a place in the front

But his eyes are too far from the ground

 

When the Zebra says it’s his right to lead

The pack points to the duplicity of his stripes

 

The Elephant trudges into the power tussle

But its colleagues dread his trampling feet

 

The warthog is too ugly

The rhino too riotous

 

And the pack thrashes around

Like a snake without a head

 

“Our need calls for a hybrid of habits,”

Proclaims the Forest Sage,

 

“A little bit of a Lion

A little bit of a Lamb

 

Tough like a tiger, compassionate like a doe

Transparent like a river, mysterious like a lake

 

A leader who knows how to follow

Followers mindful of their right to lead”

 

© Niyi Osundare 2

THE LEADER AND THE LED (Niyi Osundare)

 

Donald Macaskill

Scotland is experiencing significant demographic change. By 2045, one in four Scots will be over the age of 65. This shift demands a fundamental rethink of how we plan, deliver, and finance public services. Many bodies not least the Scottish Fiscal Commission alongside the Accounts Commission have argued that such change is urgent and immediate.

Yet despite their increasing numbers and contributions, older people are often marginalised in fiscal policy debates. Or at worst are the object of casual stereotype and victimisation.

National and local government budgets are drafted and analysed with limited attention to how public spending affects the diverse lives of older people – especially those experiencing poverty, disability, rural isolation, or multiple disadvantages. Or if they are considered it’s solely through a health or social care lens and priority.

While organisations such as Age Scotland and Age UK campaign for the rights of older people, there is currently no independent group in Scotland, or the wider UK tasked specifically with analysing the impact of public budgets on older people in the way the Women’s Budget Group (WBG) does for gender.

In this slightly extended thought piece, I am presenting one argument, namely that the establishment of an Older Persons Budget Group (OPBG) would fill a glaring gap – providing independent, evidence-based analysis and promoting age-inclusive policy development across all levels of government.

A Scotland (and UK) where public budgets and spending decisions reflect the rights, needs, and contributions of older people – ensuring equity, dignity, and inclusion for all in later life should surely be the aim of any or all political and civic leadership.

I started this thought from the premise that Scotland’s governments were not spending enough on our older citizens given their demographic weight. But in truth that’s not as simple argument to make as it might appear.

On the one hand the Scottish Government and local authorities commit significant sums to older Scots. Amongst other areas of spend we have Free Personal Care for older adults alone which costs around £900 million per annum. Local authority adult social work and care budgets rose from £4.3 billion in 2023-24, and £1.7 billion was specifically allocated for social care and integration in the 2023-24 budget. This integration involves 31 health and social care partnerships managing almost £9 billion of health and social care resources, according to Health and Social Care Scotland. Recent announcements on Winter Fuel payments to pensioners account for £100–300 million, targeted at over one million older Scots.

These figures sit within a total Scottish Budget of roughly £59.7 billion for 2024-25. On the face of it, then, older people represent large recipients.

But it’s not quite as simple or perhaps as positive. Currently, adults aged 50+ make up about 40% of Scotland’s population, with those 65+ being around 22%. If spending mirrors population share, older age groups would attract 22–40% of budget allocations. But the reality is more complex. Free personal care and concessionary travel skew toward older cohorts. Health and social care combined outstrip many other areas.

However, other demographic groups also benefit: children’s services, education, rural subsidies, universal benefits. On a strict per capita basis, older people receive robust support – but not overwhelmingly so.

So are older Scots being discriminated against in terms of fiscal spend?

Discrimination implies unfair under-provision, the absence of appropriate support, or a lack of inclusion. On pure expenditure, older Scots are not neglected. Yet any regular reader of my blogs will know how frequently I bemoan the reality that age-based barriers persist in healthcare treatment, social inclusion, and service access. That many older people – especially older women – face loneliness, digital exclusion, and precarious housing. That even at policy levels such as the Equality and Fairer Scotland Budget Statements which promise assessment of impacts on protected characteristics – often age and in particular older age are rarely singled out

Thus, while older people benefit from universal schemes, equality of outcome and lived experience may still fall short.

The House of Commons reported that the Public Sector Equality Duty often fails older people, and protections are weak. Ageism in services is still widespread: and it stated that in the NHS older patients report lack of dignity, de-prioritisation, and negative stereotyping.

This isn’t overt financial discrimination but a systemic, subtle form of injustice, rooted not in budgets per se, but in how budgets are shaped and lived.

Spending on older Scots is not negligible – it is significant, even generous. But generosity without insight risks injustice. Older people are not a homogenous mass of pensions and care. They are individuals-  diverse, local, living incomplete lives.

Similar arguments have been in the past made about women and these led to the formation of Women’s Budget Groups across the UK.

The Scottish Women’s Budget Group (SWBG), echoing the UK-wide WBG, has long scrutinised the gendered effects of budget decisions, embedding gender-responsive and care-led analysis into fiscal debate.

Their approach has both been to undertake impact-focused scrutiny: asking how spending/policy affects different genders. They have presented a robust evidence base which has sought to link budget lines with outcomes not least on care, justice and equality. And they have done all those with consistent advocacy both in parliamentary terms and in the media.

I would contend that an Older Persons Budget Group (OPBG) could usefully apply this model.

There could be many benefits such as a re-elevation of social care, health, social isolation, housing – all key ‘aged’ lenses for budgeting. Just as the WBG surfaces gender gaps, an OPBG could uncover how budget lines – like transport, digital access, social care – tangibly affect different older-age cohorts.

It would help to ensure that age becomes an explicit equality consideration in impact assessments. And importantly it would promote targeted support for older subgroups such as unpaid carers, the very old and the digitally excluded.

It would also act to accelerate inclusion into existing duties. Scotland’s advancing Public Sector Equality Duty (PSED) would benefit from formal mechanisms to assess how policies affect older populations – much in the way WBG urged for gender.

An Older Persons Budget Group (OPBG), inspired by the Women’s Budget Group (WBG), could be a transformative body in Scotland – or across the UK – providing independent, evidence-based fiscal analysis to assess how public spending decisions affect older people. Here’s how such a group might operate, structure itself, and create impact, drawing from proven models and the specific needs of ageing populations.

The practical formation and focus of an OPBG would be important.

I would suggest it needs to be an independent, and non-partisan organisation perhaps hosted by a civil society or academic institution (e.g. linked to universities, Age Scotland, or a foundation). With open membership representing the breadth of age and interests from older age advocates, gerontologists, care providers, industrial and employment interests, the creative sector etc, the OPBG would require a mix of funding sources to ensure independence and sustainability.

I’m imagining a scenario I come across all too frequently for such an OPBG.

Let’s say the Scottish Government proposes a £2bn increase in health spending but flattens social care funding. An OPBG could show that older people will benefit little from hospital-focused funding if care-at-home support declines and becomes unsustainable. It could highlight rural inequalities – where older people might be cut off from services due to reduced transport spending. It could publish a budget equity audit, noting that older women carers are disproportionately affected. And in turn it could advocate for reallocation: e.g. £100m redirected to community care and tech access for isolated pensioners.

The measure of a mature democracy is not in how loudly it applauds the aged, but in how honestly it budgets for their dignity. If we can gender our budgets, why can’t we age them too? An OPBG would not simply count pennies; it would count people – in their wisdom, their contribution, and their human worth.

So, let’s start the desire for a more equitable budgetary process which considers age as essential. And in words I have often quoted let us remember Joe Biden when he said: “Don’t tell me what you value, show me your budget, and I’ll tell you what you value.”

Donald Macaskill

Photo by Jakub Żerdzicki on Unsplash

Yesterday (July 18) was World Listening Day, which was established on the birthday of Raymond Murray Schafer, a Canadian composer and environmentalist who is seen as the founder of acoustic ecology. Born in 1933, he developed his World Soundscape Project, which laid the fundamental ideas and practices of acoustic ecology in the 1970s.

World Listening Day was established in 2010. To be honest I had not heard of the day or the World Listening Project but it started me off reflecting upon just how critical listening is in all human exchanges and relationships, but especially the case in older person care and support, when both the way in which we listen often changes with age and that the criticality of listening and memory plays such a part in ageing.

I have always been intrigued by listening, both the physical act and the power of the experience. There is a silence that sits between the words we speak. A pause. A breath. A moment of being present. But what has always fascinated me over the years and what I have found myself thinking a lot about is not noise or speech, but about the spaces in between – the almost sacred moments when we truly listen.

Listening is an act we too often underestimate in social care. It is not passive. It is not simply the absence of speaking. Listening is an ethical stance. It is a political declaration. It is a human right. In the cacophony of policy papers and targets, of assessments and checklists, listening often becomes the first casualty of our busyness. Yet it is only by listening that we come close to understanding another.

In social care, listening is the glue that binds us. It is the art of presence. A care worker crouched by a bedside, hearing more in the tremble of a breath than in a thousand words. A manager who pauses long enough to really hear the fear in a family member’s voice. A system that slows down just enough to hear the hopes and hurts of those it serves.

To listen is to love. To listen is to dignify. To listen is to recognise the voice behind the silence, the soul behind the sound.

But listening changes over time, certainly the way I have listened has.

As we grow older, our ways of listening shift. Not just physically, as hearing fades, but emotionally and spiritually. Age does not only soften the body; it often sharpens the spirit. The older we become, the more we learn to hear what is not being said.

In my experience of being with many older people I notice that listening becomes less an action of the ears and that other senses are used much more. Listening happens with the eyes. With touch. With memory. Listening becomes textured with the colours of past pain and joy. It becomes an act of remembrance, of legacy, of presence. But all too often, older voices are filtered out, dismissed, or reduced to whispers in the policy halls.

If a day like World Listening Day means anything it should help us to focus better on the central priority of listening in social care, and also to help us confront the systemic deafness to older age. We must, I think, re-tune our ears to voices shaped by decades of living, by grief and by grace. And that is all the more the case when we consider the role of listening for those living with dementia.

Because when dementia enters the room, listening takes on new hues. The linearity of conversation may dissolve. Time may warp. Words may wander. But the need to be heard remains as fierce and vital as ever.

Listening to someone living with dementia demands that we listen not with our ears, but with our whole selves. We listen through gestures, through repeated phrases, through the cadence of a familiar song or the shape of a gaze. We listen knowing that meaning is not always in the sentence, but in the connection. We listen for the emotion beneath the word. We listen not to fix, but to witness.

If social care is to be truly human, it must become a listening culture. One that places time before task. One that honours silence as much as speech. One that accepts that the people we support are not problems to be solved, but stories to be heard.

We need systems that make space for listening – not just in individual interactions, but structurally. Listening must be embedded in inspections, in commissioning, in care planning, in leadership. For if we do not listen, we do not know. And if we do not know, we cannot care.

But let us be honest in recognising that that aspiration seems a very far distance from the realities of the moment, where we are shamefully increasing the contracting of 15-minute visits which strip people of dignity and compassion and certainly give no space for listening which is surely the most essential component of preventative care and relationship formation.

The whole of the social care system, not just those at the frontline, needs to learn to listen better and to commit to a deeper listening.

In the words of the poet:

‘To Listen”

after the quiet of care

 

I have sat beside the hush of pain

where words refused to come,

and heard in silence

what speech could never carry.

 

To listen

is not to wait your turn,

but to offer your breath

as shelter.

 

It is the soft art

of placing ego

at the foot of another’s need.

Not to fix,

but to witness.

Not to solve,

but to stay.

 

I have listened with my eyes

when memory was a maze,

when time no longer followed rules,

when a name could not be found –

yet love, somehow, was still recognisable

in the reach of a hand.

 

I have listened through repetition,

through the rhythms of dementia –

where truth is not in sequence,

but in sincerity.

And each telling

is its own kind of courage.

 

To listen

is to lay down power.

To hold the weight of another’s moment

without trying to reshape it.

 

It is a kind of prayer –

not always spoken,

but always heard

if we choose to be present.

 

So today,

before we speak,

let us listen –

with our ears,

our eyes,

our time,

our hearts.

 

For in the act of listening

we offer the most human gift of all –

recognition.

 

Donald Macaskill

In Scotland, where summer is let’s be honest somewhat fleeting – a brief burst of light and warmth between long winters and now seemingly over by May – the summer season here as elsewhere can sharpen grief for people. While shorter days are often linked to loneliness, the pressure to “make the most” of Scotland’s precious sunny months can make bereavement feel even more isolating.

Being honest I have probably never thought of summer as a hard season for those who are bereaved until I was stopped in my tracks the other day by someone who said to me that they hate summer – not because of the weather – but because the long days and nights makes their loneliness more intense. And there was me thinking that the cold winter days were the hardest season for grief.

But then I began to think of my own childhood holidays and upbringing. No sooner had the school bell beckoned the end of the term – and sometimes even before – I was packed off with a few clothes onwards to Skye and long days on beach and croft.

For many older Scots, summer once meant Highland holidays, Doon the Water adventures, garden gatherings, or coastal walks with family and loved ones. Now, the same light highlights an absence for many. Norman MacCaig captures this well in ‘Memorial’:

“Everywhere she dies. Everywhere I go she dies.

No sunrise, no city square, no lurking beautiful mountain

but has her death in it.”

Published in 1991 the poem laments the loss of his sister Frances and described how his loss is ever present, in season and out. It is constant.

Summer is often portrayed as a season of joy – long days, family gatherings, and the warmth of the sun. But for many older people, especially those who are bereaved, summer can amplify loneliness rather than ease it. While winter is frequently associated with isolation and depression, the expectation of happiness in summer can make grief feel even more isolating.

Grief does not fade with the seasons. Grief does not melt in the sun. It lingers. For older adults, summer’s sensory richness – the scent of cut grass, the sound of children playing, the warmth of the sun – can trigger vivid memories of loved ones no longer present.

A 2023 report by the Mental Health Foundation Scotland found that 28% of over-75s felt lonelier in summer, citing “seeing others socialise” as a trigger. Age Scotland’s 2022 survey revealed that 42% of bereaved older adults avoided summer events (e.g., community galas) due to grief reminders. And in my own memory corners research from the University of the Highlands and Islands highlighted that older bereaved adults in rural areas face compounded loneliness in summer, as tourism and visitor traffic contrast with their static sorrow.

Further still research from the University of Stirling found that seasonal changes can trigger memories, making anniversaries of loss more acute in summer. The contrast between external vibrancy and internal sorrow can lead to what psychologists’ call “disenfranchised grief” – sorrow that feels unwelcome or unacknowledged in a world that expects happiness.

It seems inescapable then that summer is hard and I suspect our targeting of issues such as loneliness lacks seasonal considerations. Indeed, organisations offering grief support such as Cruse Scotland report higher demand for counselling in June-August.

One of the challenges of bereavement in older age is that it often goes unseen. A 2020 study by the University of Manchester found that older people are significantly less likely to seek formal bereavement support, despite reporting high levels of prolonged grief and emotional distress.

In care homes or supported housing, expressions of grief may be muffled by a desire not to burden others, or silenced by the myth that older people are somehow “used to death.” Nothing could be further from the truth. Every loss is unique. Every goodbye leaves its own scar.

And in summer, the world’s brightness only sharpens the shadow of absence.

Added to this much of our cultural language around grief is shaped by stages and steps like with neat boxes of denial, anger, acceptance. But grief, particularly in older age, is cyclical, tidal. It comes in waves that make nonsense of calendars.

A warm June day might bring unbearable heartache for someone whose partner died last summer. A July sunrise may spark memories that lead to tears over breakfast. As researchers like Stroebe and Schut argue in their dual process model, healthy grieving involves oscillating between loss-oriented and restoration-oriented experiences.

In other words, older people grieve and live at the same time. They water the garden and weep for who are not there to see it bloom.

So how can we, as communities, care providers, neighbours, respond?

First, by acknowledging. By refusing the polite silence that often follows death, particularly in older age. We need to create cultures in our care settings – and in wider society – where grief is not only allowed but welcomed, named, shared.

Second, by creating opportunities for ritual and remembrance. Summer is a perfect season for memory walks, remembrance gardens, shared poetry readings, and intergenerational storytelling. We need not wait for anniversaries or official memorials to honour those who are gone.

As the poet Mary Oliver wrote in When Death Comes:

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

I was a bride married to amazement.”

Older people carry with them lives of amazement, love, and loss. We owe it to them to witness the whole of it, especially in seasons that hide sorrow in sunshine.

In our policy and practice, we talk about trauma-informed care. Let us also be grief-informed, attuned not just to clinical depression but to the slow ache of bereavement. Let us train staff not only in medications but in listening; not only in safeguarding but in soul-holding.

And let us never forget that love, when lost, does not disappear. It becomes memory, it becomes pain, it becomes the quiet pause in a summer afternoon when an older person turns toward a seat that used to be filled.

Grief does not fade because the sky is blue.

But neither does it mean the absence of joy forever. For even those in sorrow, there can be glimpses of laughter, tastes of delight, moments of music.

And sometimes, that is enough.

The Skye poet Eilidh Watt (nee Macaskill) brought up in the village next to where I spent so many summer holidays, once wrote:

“You were the tide in June, full and fierce,

And now I walk the shore alone,

Seaweed in hand, memory on skin,

And no echo of your voice in the gull’s cry.”

Donald Macaskill

Photo by Elly M on Unsplash

If these themes interest you – you might want to join the Scottish National Bereavement Charter Group at a free event in Glasgow on the Future of Bereavement on 28^th August 20025 – more details here https://scottishcare.org/the-future-of-bereavement-support-in-scotland-28-august/

The following is based on a talk which opened the inaugural Scottish Care, Care Tech Assembly held in Glasgow on 19^th June 2025.

I want to share a few personal thoughts about technology within social care and to do so under a human rights umbrella. And I want to do so from the perspective of someone who has been fascinated by tech and its potential to enhance human connection and humanity for an awful long time.

And I suppose I am also making a bit of an assumption as I start these reflections that I am among people who believe that technology, when rightly held, can serve humanity rather than diminish it.

The Past: listening to the echoes

Let me take you back to a room in a care home in Glasgow’s west end, many years ago. I remember as a student sitting with Mary, a former schoolteacher, now living with dementia. She was holding a photo of her late husband. It was tattered at the corners from love and remembering.

There was no iPad. No voice assistant. No tech-enabled reminiscence therapy. Just two humans, sharing a moment.

Technology hadn’t yet found its way into her world – but care had. Deep, relational, person-led care.

That care home was just along the road from the school I went to and the school she had once taught in. We were on the edge of the University campus – the same University where years earlier I had walked with my classmates one afternoon to visit the Computing Dept. I’ve spoken before about that experience – about how our class was invited along one afternoon to see what was, at that time, reputed to be one of the world’s fastest computers.

It was a whirring series of metal cupboards which literally filled a room with a standard screen and keyboard to operate them. This was well before the era of the ‘mouse’, so all instructions were laboriously typed in by complicated code.

What struck me then was the sense of sheer wonder with which the technicians and scientists viewed their work and its creation. It filled me with both a lifelong fascination for, and indeed a fear of, the power and potential of technology to change the world I inhabit for good and ill.

One of the men working on the computer at the time mentioned that when we had reached his age – an elderly 40! – the computer we saw that day would be the size of a cigarette packet. We laughed then. Nearly 50 years later after my flirtations with a BBC computer, an Amstrad, and an enduring love affair from the earliest Apples, loads of floppy discs and CD-ROMs, I am no longer laughing. The truth of a processor 1000s of times faster and more powerful than the machine that filled that Glasgow room is in the laptop I carry every day and the smartphone whose presence is, reluctantly, my essential life tool.

But sitting with Mary just along from that room and maybe not much more than a decade later we were to a large extent in a technology free zone.

And I suppose if you had asked me then in the past, I would not have even contemplated that tech could be so contributive to and could potentially enhance care. It wouldn’t have been in my worldview.

Then over time myself and others would have expressed fears that technology let loose would replace that care – that somehow, warmth and connection would be coded out of our lives.

I reflected that in my own writing in 2017-18 when I wrote Tech Rights where I explored the interplay of human rights and the potential of machine learning, Ai and the internet of things and suggested that there was as much promise as well as danger in the future.

So, what of the present?

The Present: dancing with change

Today, we stand in a time of rapid digital transformation. In Scotland, digital social care records are becoming the norm, not the exception. We’ve seen technology bridge gaps, not widen them – when done well.

Care homes have used iPads to reunite families over FaceTime. Sensors now help monitor health in the background, offering dignity and safety without intrusion. People living in their own homes are using smart tech to remain independent for longer.

But the truth is, this progress wasn’t born from a boardroom or a policy paper. It was born from pragmatic intent and a ground-up desire to do things differently – and yes let’s be honest also to do things with an economy of time and cost. The current and I suspect the future design of tech will be responsive and reactive to circumstance and to need more than planned intent and policy.

And when the history of tech in care is written the influence of the pandemic will be clear and transparent.

Our present was born from a pandemic – from necessity, from desperation, and yes sometimes even from love.

We had to learn quickly that technology must never be the master of care. It must be the servant of humanity- and especially of the most valuable.

What does the future hold?

It holds possibility. But only if we choose it wisely and in some places that future is already happening…we are already witnessing circumstance where an older person’s voice activates not just a light, but a lifeline of connection and assurance. We are and can create a future where digital tools aren’t cold, but compassionate. Where artificial intelligence doesn’t make decisions for people, but with people. A future where every innovation asks not “What can this do?” but “Whom does this serve?”

But it is how we build that future, design that tomorrow, which is all important and which an event like today contributes so much to.

Many of you will know of the work of the Oxford Institute for Ethics in Ai and the Digital Care Lab and how after over a year of creative collaboration and co-production, a framework for the responsible, ethical and rights based use of Ai in social care has been developed. That work is progressing, growing and becoming even more influential and I would commend it to you.

But the art will be, the essential requirement will be, how do we turn such frameworks and models into the automatic and instinctive actions of a system and of stakeholders who in straitened economic times and faced with the demands of immediacy might be tempted to take short cuts, go for the cheapest or easiest option, both of which usually risk the rights, autonomy, control and agency of the citizen?

The Oxford work and others have shown that the critical way in which you embed an ethical and human rights-based approach has to be through the democratising of design and the granting of control and agency to citizens. Too often I fear we pay lip service to this fundamental principle – the sense of individual citizen control over data – even a discussion I had this week on the principle of revocability – showed just how hard it is for systems which get too big, too distant from the user, from the citizen whose story is the data, to be open to approaches where citizens can re-write, change, edit and remove their data.

The excuse often given for the radical individualising of control around Ai, tech in general as well as in care and support, is that it is too difficult to get to the individual level – that’s an excuse I heard so often during the blanket decision making of the pandemic – and it is today tosh and nonsense.

A colleague recently told me about the work of Pol.is and the more I have looked at it the greater its potential for democratising decision and consent seems to me. Some of you might know of the Pol.is work which has been going on and developing in Taiwan.

Pol.is is a digital tool used in Taiwan to facilitate large-scale public deliberation. It was notably employed by the Taiwanese government as part of the vTaiwan and Join platforms to gather public input on complex policy issues.

‘How it works:

• Citizens respond to open-ended questions and vote on other people’s comments.
• Pol.is uses machine learning and data visualisation to group participants based on shared opinions, highlighting areas of consensus and disagreement.
• Unlike traditional polling, it avoids polarization by encouraging constructive dialogue and surfacing common ground.’

It is a tool which already has helped to bring democracy and decision making to very small and local community levels – its adaptation and use in settings such as residential care, community groups has, I think, huge potential, not least in its approach to inclusivity and achieving consensus and agreement.

Just imagine how such an adapted tool to enable individual participation and decision making could be used in a social care context around data control, management and use?

When I wrote my extended thought piece on TechRights I was very clear that the future developments of Ai, machine learning, the Internet of Things and robotics could and should only be enabled through a robust and ethical human rights framework – everything I have seen in the intervening 8 years convinces me even more of the validity of that assessment.

Human rights have to be the baseline not just bolted on; we need person led tech not just person-centred design.

And we continually need to re-design how we implement rights in technical practice. I think it is the task of all of us, no matter where we are in the pathway of design and development, in use and implementation in care environments, to consider our human rights and how they impinge in the use of tech and digital.

Here is my latest musing: a Human Rights Framework based on the acronym H.U.M.A.N.I.T.Y.

H.U.M.A.N.I.T.Y. Framework

H – Human Dignity

• AI must enhance, not replace, relational care.
• Systems should respect inherent human worth, prioritising the individual over efficiency.
• Insist on the truth that care is a human act, not a mechanical function.

U – Understanding

• AI must be developed with contextual awareness of care realities.
• Systems should reflect the lived experience of people receiving and giving care.
• Understand the cultural, emotional, and social nuance, which are vital to ethical care.

M – Moral Responsibility

• Those designing and deploying AI must act with ethical integrity.
• Care providers have a duty to ensure AI is used in ways that align with care ethics and human rights.
• There needs to be a stress on values-led leadership and responsibility in the care sector.

A – Autonomy

• Individuals have the right to make informed choices about how AI affects their care.
• AI systems should promote control and consent, not paternalism.
• Autonomy is essential for citizenship and empowerment in care.

N – Non-Discrimination

• AI must be designed and tested to eliminate bias and promote equity.
• It should support inclusivity, particularly for those often excluded: older adults, disabled people, ethnic minorities.
• There should be a built in commitment to social justice and fairness.

I – Integrity

• Use of AI must be transparent, honest, and accountable.
• Integrity means being able to explain and justify AI decisions, especially when they affect people’s lives.
• Create a sense of moral coherence in digital and care governance.

T – Trust

• Build trust through co-design, openness, and clear communication.
• Trust is sustained through relationships, not just systems.
• Trust is the glue of good care and support – and it must be protected in tech use.

Y – You-Centred

• AI in care and support must be person-led, not system-led.
• It must serve the individual’s rights, values, and story – not just operational efficiency.
• Care and support are affirmed as a deeply personal, relational, and human experience.

Last year, I visited another care home. There, a woman named Ishbel had started using a voice assistant. She said, “I call her Alexa, but I treat her like she’s my lassie. I tell her goodnight, and sometimes, she tells me the weather. But mostly, she makes me feel I’m still part of the world.”

That’s the heart of it.

We’re not building devices. We’re building belonging.

So, as we look ahead, let us walk forward not with fear of what we might lose, but with hope for what we can gain.

Let us shape a future where digital doesn’t dim the light of care, but reflects it—brilliantly, boldly, and beautifully.

Let us- together- hold hands with tomorrow.

 

Donald Macaskill

 

Photo by Robs on Unsplash

The last few weeks and indeed the month of June has seen a hive of activity in the world of policy and politics around health and social care. From the passing of the Care Reform Bill to the publication of the Health and Social Care Service Renewal Framework alongside the Population Health Framework there has been no shortage of meaty content for the policy and political anoraks to feast upon. Sometimes these actions can seem very distant from the delivery of care and support and even more so from the recipients of social care and health services. Just occasionally the words are worth taking note.

In what follows I want to reflect on some of the major events and key publications. Admittedly this is an initial reflection because I think it will take some time for the full range of ideas and plans to come to their fullest fruition.

The aspirations of the Health and Social Care Service Renewal Framework (2025–2035) are to be admired. Its aims are to take a fresh, strategic leap toward a future where Scotland’s health and social care are integrated, prevention-led, and digitally enabled. Few of us would find fault with this – grounded as they are on the almost forgotten work of the Christie Commission. They are anchored by five principles – Prevention, People, Community, Population, and Digital. Again, few would object to such a focussed analysis and the aspiration and tone which desires a decade of transformation.

Meanwhile, the Population Health Framework commits to closing health inequalities, shifting resources to upstream social determinants, and embedding place-based prevention. Together, these documents sketch a bold vision: health and care built not just for people, but around them.

I read both reports against the backdrop of the discussions I and others have been having which were contained in an Open Letter published in The Scotsman. This letter co-signed by leading clinicians and practitioners across health and social care in Scotland, and informed by Enlighten, argues that our system is “unsustainable, overly complicated, difficult to navigate” and goes on to demand long-term, collaborative reform.

I am therefore pleased that taken with the two published reports there seems to be an emerging ground for consensus and indeed collaboration.

The shared and consensual path forward seems to be growing, it is one which envisages:

• Shifting services upstream, reducing reliance on acute care, and investing in community-based surroundings – all hallmarks of smart, modern reform.
• Principled planning -moving from siloed service design to networked, population-focused approaches.
• Digital-first ambition – a necessary catalyst for efficiency, access, and personalisation.
• Cross-sector unity, echoed in the Open letter’s plea for independent, third sector and community partners to be full co-designers of reform.

There is real potential therefore in the work that has been and is being done, but it would be disingenuous of me to not also comment about what strikes me as being missing so far, not sufficiently emphasised and what steps, I believe, could make progress upon the shared aspirations more likely to succeed.

Bold though it is, the Framework underplays the significant contributive role which social care can deliver for Scotland and most importantly from my context for the health and wellbeing of all, not least older Scots. At times both documents are written too narrowly from an NHS centric lens – maybe inevitable given their origins, but I think they can also be improved by using a more communitarian and social care lens.

Take for instance Scotland’s world-leading and seminal legislation and basis of accessing social care, the Self-Directed Support (Scotland) Act (2013, amended 2025) and the new Care Reform (Scotland) Bill (passed June 10, 2025). Both I would suggest offer powerful mechanisms to enhance the Service Renewal Framework and the Population Health Framework – especially for improving care for older Scots in care homes and at home. Allow me to illustrate some examples:

Self‑Directed Support Act (SDS)

Choice and control are central and key principles of the way in which social care is delivered in Scotland. We have not always got it right and have not always adequately empowered those who use supports – but be that as it may – that these two principles are central is of very real importance and should not be brushed over or set aside. There was a long struggle to shape the SDS legislation and to base it on principles of greater personal autonomy, control, and empowerment. SDS enshrines the rights of people who receive care to shape how, when, and by whom it’s delivered – vital for older Scots wanting autonomy in diverse settings. The absence of its centrality in the new reports is more than disappointing.

One of the major goals of the new Framework is to re-align service provision – SDS if properly embedded (and not in the resource deprived and patchwork way of the moment) can genuinely shift services upstream by centring individual needs, supporting the Prevention, People, and Community principles of the Framework. The recently renewed statutory guidance for SDS can be used to extend SDS into care homes, enabling residents to even more than they do now to better direct elements of their own daily lives – activities, meals, visits – empowering both dignity and quality. Others and I have long argued that to limit the ability of older people in residential care to have full control through SDS is a limitation of their rights.

Then when we consider the Care Reform (Scotland) Bill again there are numerous and very real opportunities to bolster the reform goals.  This is most obviously the case in the new rights to respite for unpaid carers. Indeed, one of the glaring omissions of the Strategic Reform Framework is the virtual absence of recognition of the critical role unpaid carers pay in the whole health and social care economy. The new law mandates Councils to assess carers and provide funded breaks which aligns with the emphasis within the Framework upon prevention (by reducing burnout) and People (supporting caregiver health). It directly serves older Scots living at home.

The new Bill also furthers the aims of the new Frameworks in its emphasis on the continuity of care which secures stable care packages even if individuals move across local authorities -reducing disruption and supporting independence and long-term care planning, which is again in line with Population Framework aims.

But it is perhaps in the wider area of reform that there is an emphasis which can potentially help to properly achieve the aims of both the Frameworks. There is a real opportunity over the next few weeks and months for the whole system to build on the Bill’s emphasis on ethical commissioning, to embed Fair Work standards, sectoral bargaining, and clear progression ladders – all key to staffing stability across both home and residential care. And most obviously the significant digital and data achievements and innovations of aged care in both homecare and residential care have much to teach the wider acute, secondary and primary care communities.

The SDS Act and Care Reform Bill aren’t just legal formalities- they are levers to deliver the visionary ambitions of the Frameworks. When applied strategically, especially in care homes and homecare, they can drive real change, embed prevention, increase autonomy and frame stability and sustainability.

The Frameworks show we’re on track. The open letter tells us we have to be bolder, faster – and more inclusive. But without a social care turnaround and emphasis, I fear, this ambition remains incomplete. That will inevitably mean that we need political courage across the Parliament in making fiscal decisions that truly see the balance of care and support, move from the acute and secondary NHS hospital sector to community health and social care. We have talked about this for a long time and now we must see action rather than aspiration. How that is done and whether additional funding comes from re-alignment of other priorities is clearly a political decision, but the necessity of action should be inescapable. We cannot continue to see social care solely through an NHS lens, care and support in community offers true preventative advances and it is that we need to focus on rather than a singular obsessive focus on delayed discharge. Social care is more than that.

It is surely our mutual collaborative responsibility to now start to transform strategy into practice and go beyond grand vision to tangible improvement in the daily lives of older Scots. I am certain the independent and third social care sector is up for that task.

Donald Macaskill

Photo by Alex Skobe on Unsplash

 

Today (21^st June) is World Music Day – a time when across the globe, communities gather to celebrate the universal language of melody, rhythm, and song. When radio stations take advantage of the day to entice us to listen more and when a plethora of local events celebrate the day.

I have been an avid listener to so much music since my earliest childhood days when like so many of us the music our parents listened to shape our eardrums and taste. For me it was a mixture of Gaelic song filtered by Jim Reeves, Elvis, the Beatles and Johnny Cash. Then with the maturity of age the eclectic mix of Crowded House, Abba, Runrig and my source of all inspiration to this day Bruce Springsteen and the E Street Band. Our music shapes, moulds, inspires and conditions us.

So, as I reflect of World Music Day, I do indeed think of all the gigs and events I have been lucky enough to attend but I also think of the less grand and quieter, more intimate spaces where music has exerted its power over me, from my family front room to student flats and outside buskers.

But over the last few years in particular I have grown to appreciate the tremendous power of music in places and spaces which are even more hidden and quieter than the usual performance venues we might be familiar with, in our care homes, in hospital wards, in the living rooms of those living with frailty, dementia, and decline. It is here, often behind closed doors, that the true miracle of music quietly unfolds.

For older people, music is not merely entertainment. It is connection. It is comfort. It is continuity of self. It is therapy. In these spaces, music is a vessel that carries the individual across the sometimes-frightening gaps carved by time, illness and memory loss.

As a young parent I was acutely aware of the work of music psychologists in terms of early brain formation, and you only have to look at the music catalogues to see the downloads from Bach for Babies to Mozart for Toddlers. It has taken us a bit longer to validate the significant role that music plays for older people care and support.

Modern research has increasingly begun to validate what many carers and families have long intuited: music accesses parts of the brain often untouched by disease. The pioneering work of neuroscientists such as Oliver Sacks, and more recently the international consortiums studying music and dementia, show us that the neural pathways involved in music processing – particularly rhythm and melody –  are uniquely resilient, often remaining intact even as cognitive faculties decline.

In functional MRI studies, regions such as the medial prefrontal cortex –  areas tied to autobiographical memory and emotional regulation –  show sustained activity when individuals listen to personally meaningful music, even in advanced stages of dementia. In one striking study published over a decade ago in 2015, researchers observed that musical memory can remain accessible even when other forms of memory are lost, offering individuals a bridge to their sense of self.

Music appears to activate broad networks of the brain simultaneously: motor areas, language centres, limbic regions responsible for emotion, and –  perhaps most importantly – the default mode network linked to self-awareness. It is no wonder that, in so many cases, individuals who struggle to recognise loved ones can nevertheless sing along, note-perfect, to the songs of their youth.

I have to confess that in not a few places I have argued that it is important that we recognise the sheer value in people being entertained and in taking enjoyment from sound and music. I also believe it is critical that we also recognise the profound benefits which can be gained by people at any age in life participating in and creating music. Life should not just be about passive receipt of the creativity of others but a participation in self-expression and creative musicality. But be that as it is , I sometimes feel we lose sight of the sheer therapeutic value of music and musicality, and do so at our cost.

Beyond the astonishing resilience of musical memory, a growing body of research has documented the tangible benefits of music-based interventions for older people.

Randomised controlled trials have consistently shown that music therapy can reduce symptoms of anxiety and depression in older adults, particularly those living in long-term care settings. The act of listening to, or creating, music stimulates dopamine release, contributing to improved mood and wellbeing.

In dementia care, personalised music playlists have been shown to reduce agitation, restlessness, and the use of antipsychotic medications –  a profoundly important finding in light of concerns over overmedication in care.

Even more so whilst music cannot reverse cognitive decline, engaging with music – whether through singing, drumming, or listening – provides meaningful cognitive stimulation, maintaining attention, language, and even aspects of executive function.

And perhaps most importantly, music offers a shared space for relationship, for communication beyond words. It creates opportunities for care staff, families, and care home residents to connect on a deeply human level.

Of course, not all music is created equal. The most effective musical interventions are not generic playlists of “golden oldies”, but carefully curated selections rooted in the personal histories and preferences of each individual. The song that stirred a heart in 1955 may not be the same as the one cherished in 1975. That is why the amazing work of Playlist for Life deserves every bit of focus and support.

In this sense, music care becomes an act of human rights-based care – one which honours the individuality, autonomy, and lived history of the person. We must resist the temptation to treat older people as a homogeneous category and instead engage in the work of listening to their life stories, through and alongside their musical tastes. I have no doubt a lot of my story is tied into by walking alongside Springsteen whilst others would run a mile from that journey !

If we are serious about reimagining care and support in Scotland and across the UK, then music should not be seen as an “add-on” or a luxury, but as an essential part of care practice. It has been easier to argue that point and case for residential care, it has been well-nigh impossible to convince commissioners and financiers of the value and merit in prescribing music and its therapeutic use in care at home. Yet, if the benefits of music not least as a preventative tool for decline and deterioration – are true of residential care then that truth sings even louder in someone’s own home. It is not fanciful or naïve to argue that we should have music as a core part of relational, time-flexible, person-led homecare. This is  surely the heart of social prescribing?

We need greater investment in training care staff to use music therapeutically; partnerships between care homes and professional musicians; research funding to deepen our scientific understanding; and national policy that recognises the centrality of the arts to wellbeing across the life course.

In the end, music reminds us that identity endures even as so much falls away. The rhythm of a waltz, the swell of a hymn, the first few bars of a favourite song – these can bring a spark of recognition, a light behind the eyes, a squeeze of the hand.

And that is why, on this World Music Day, I find myself filled not only with gratitude for the gift of music, but with a renewed sense of responsibility. To ensure that every older person, regardless of circumstance, has the right to their song. The right to be heard. The right to be remembered.

Because, in the words of the late neurologist Oliver Sacks:

“Music can lift us out of depression or move us to tears – it is a remedy, a tonic, an orange juice for the ear. But for many of my neurological patients, music is even more – it can provide access, even when no medication can, to movement, to speech, to life. For them, music is not a luxury, but a necessity.”

I will give the last word to The Boss, who speaks of the power of music in “No Surrender” (from the Born in the U.S.A. album, 1984):

“We learned more from a three-minute record, baby, than we ever learned in school.”

This line beautifully captures how deeply music can shape identity, inspire action, and teach us about life- often more powerfully than traditional education. It’s one of Springsteen’s most quoted reflections on the transformative force of rock and roll. And for those whose sounds are different – all music changes our worlds if we allow ourselves to hear.

 

Donald Macaskill

Photo by Marius Masalar on Unsplash

Over the years I’ve written quite a few times about men’s health and some of the challenges that are faced in improving the health of the male population. I’m back on this theme this week as we sit towards the end of Men’s Health Week 2025 which runs from the 9th to the 15th June.

Amongst all the focus on male health there is a group which is even more forgotten about and that is the specific needs of and issues facing older men.

Recent data paints a concerning picture. Life expectancy for men in Scotland stands at 76.8 years, with a stark 13.2-year gap between the most and least deprived areas. Chronic conditions such as obesity, affecting 32% of adults, and cerebrovascular diseases, with incidence rates 32% higher in males than females, further exacerbate health disparities.

Physical activity levels are suboptimal; only 37% of adults aged 75 and over meet the recommended guidelines, with men in this age group slightly more active than their female counterparts but still not engaged in levels of activity which would bring real physical benefits.

Mental health is another pressing issue. Loneliness has been identified as a significant public health problem, with 58% of Scots over 50 experiencing loneliness most or all of the time . This sense of isolation is exacerbated by the fact that nearly 40% of Scottish households are single-person dwellings, the highest rate in the UK. Men in particular are more likely to face periods of loneliness in older age not least when a partner dies.

There is a great deal of appropriate emphasis upon preventative care and support, around interventions which can help address inequalities and enhance wellbeing and health. One area which can undoubtedly benefit from such approaches is male health, and a major strand in that approach are social care services.

However, the current system has been criticised for being fragmented and crisis prone. To better serve older men, social care must evolve in ways which are responsive to the needs of a distinct population and please, please, please the talk of prevention and early intervention must be backed up by an adequacy of resource even if it means realigning existing spend.

We know what works well and perhaps the model with the greatest success is the Men’s Shed movement. Such community-based approaches provide spaces for older men to engage in meaningful activities, fostering social connections and improving mental health. Similarly, the Sporting Memories Network uses sports reminiscence to connect with older men, particularly those living with dementia.

We know on the ground that targeted interventions are needed to combat loneliness among older men. This includes promoting social engagement opportunities and ensuring access to mental health support services. The crippling impact of loneliness will not be addressed by happenstance and a blanket one sized fits all approach – it has to be targeted. It is therefore really disappointing that there has been year on year cuts to the resources that third sector organisations require to keep these approaches and services going. To say nothing of the potential to address male loneliness if we ever allowed ourselves to fund a homecare system that gave time, conversation and space to the care and support of older  men.  Only with such support would frontline staff and social care organisations manage to be more equipped to understand better issues such as masculinity and cultural norms that may impact men’s health behaviours.

I have looked in vain for a cross policy and whole system Men’s Health strategy in Scotland. This is not to diminish the good work that is underway not least the focus on male suicide but I really do think the time has come for such an approach, not least as there is now a drive from the UK Department of Health and Social Care who launched a 12 week consultation in spring of this year to inform their first ever Men’s Health Strategy.

The reasoning for such an approach is not just the factual data that tells us that 1 in 5 men die before the age of 65 in the UK; that 3 out of 4 suicides are by men or that 37% of men admit to hiding their mental health issues from their partners.

The data is damning and inequalities are only growing and I would argue only a whole system wide cross-cutting, multi-disciplinary approach to men’s health will make real difference – especially if it is rooted in social care.

It would potentially help us to leverage our existing structures (community nursing, care-at-home) to proactively reach older men by offering check-ins, screening, and early support. It would potentially offer us a national approach to the expansion of existing community-based interventions such as Scottish Men’s Sheds, Sporting Memories, walking groups, book clubs and foster the development of new approaches to appeal to emerging generations of men.

A national Strategy would also critically help us to fill the huge knowledge gaps we currently have around male health. It would enhance the collection and public reporting of men’s health outcomes (e.g. life expectancy, mental wellbeing, social isolation) by age, gender, and deprivation.

And lastly but perhaps even more importantly such a Strategy could drive increased national awareness and knowledge. Public campaigns highlighting men’s‑health issues (e.g. heart health, mental wellbeing, cancer screening), with a focus on older men and reaching them via trusted community channels could all become a priority.

So, as we come to the end of Men’s Health Week for another year perhaps some of our political leaders and aspiring parliamentarians could take the lead in helping us to develop a national Men’s Health Strategy?

I leave you with some words from the poet and celebrant Marc Lemezma who beautifully captures the inner struggle many men face – hiding their pain behind pride, and the liberating power of someone simply asking with care. It’s a heartfelt reminder that support can start with a single question and that vulnerability is not weakness but connection.

Remember to ask and listen with care

For the most common of troubles are the hardest to share

They hide deep within us;

They never will show

Yet these are the feelings we need to let go

But we let foolish pride colour our eyes

And run from our burden till there’s nowhere to hide

We give them a home; yet they eat us away

We think they’re the answer; they’re just there to betray

You cannot imagine or begin to dare

How these are the feelings that every man shares

Yet all that it takes is for someone to ask

And the love of a friend can pierce through the mask

So remember to ask, for the silence may break

And may just be the lifeline they needed to take

Donald Macaskill

Next week the 9th to the 15th of June is the annual Carers,Week. This year the focus is all about ‘recognising our carers’ and a plea to acknowledge the invaluable contributions of unpaid carers.

Right across Scotland today, in tens of thousands of homes, a silent workforce labours tirelessly – these unpaid carers are the backbone of our health and social care system. They are the daughters, sons, spouses, neighbours, and friends who, without fanfare, provide essential care to loved ones. If the contribution of paid carers to Scottish society is massive and unrecognised, that of our unpaid carers is monumental and unsupported.

Recent data underscores the scale of unpaid care in Scotland. The 2022 Census recorded over 627,700 unpaid carers- a 27.5% increase since 2011. Their collective efforts are valued at approximately £15.9 billion annually.

These women, men, young people and children provide indispensable support, often stepping in where formal services fall short. Sadly, this is even more the case as savage cuts are resulting in the loss of so many formal lifeline social care services. Carers in their roles encompass a wide range of responsibilities, from personal care to managing complex medical needs. Without them, the formal health and social care systems would face insurmountable challenges and in truth would crumble.

Despite their critical role, unpaid carers face significant pressures. A 2023 survey revealed that over half (52%) of carers reported an increase in their caring responsibilities over the past year, with 75% unable to take a break when needed. Many feel overwhelmed, with 63% reporting feelings of being constantly overwhelmed due to their caring duties.

The health impacts on many unpaid carers are enormous with chronic stress, sleep deprivation, and isolation often reported. A Public Health Scotland report in 2022 found that unpaid carers are twice as likely to experience long-term health conditions as non-carers.

Financial strain is another pressing issue. Unpaid carers are 56% more likely to experience poverty and 60% more likely to be in deep poverty compared to those without caring responsibilities. This economic hardship often forces carers to reduce working hours or leave employment altogether, exacerbating their financial vulnerability.

The challenges faced by unpaid carers have broader implications for the social care system. As carers become overwhelmed and unsupported, the risk of care breakdown increases, leading to greater demand on formal services and at a time when demand is already soaring and the capacity to respond is diminished. This not only strains resources but also impacts the quality and continuity of care for those in need.

Moreover, the reliance on unpaid carers masks the true demand for formal care services, leading to underinvestment and inadequate policy responses. Recognising and supporting unpaid carers is therefore not just a moral imperative but also an urgent necessity for a sustainable social care system.

To address these challenges, a multifaceted approach is required and much greater political priority: I would argue that this would include amongst other things, that the Carer’s Allowance Supplement needs significant investment and increase, even with a recognition of the summer payment this past week. In addition, that respite should be seen as a fundamental right and such guaranteed breaks must be enforceable, not a postcode lottery. We also need to do much more in terms of workplace protections so that carers are not forced out of jobs, especially older carers.

And lastly, I have lost count of the tables I’ve sat at and rooms I have been in which have been critical to social care provision and the voice of unpaid carers is absent. Unpaid carers and their representative organisations require formal recognition as being integral partners in the health and social care system, involving them in decision-making processes.

By implementing these measures, we can slowly begin to alleviate the pressures on unpaid carers and build a more resilient and compassionate social care system.

To close, I leave you with a poem which reflects on the fragility and impact of unpaid care:

I’m holding it together

 

I’m holding it together – just.

The fragments of those days when

you made all the decisions, and I

was pleased just to follow

are there, fragile but still.

I’m holding it all together – I think.

The tears inside swelling to leave

when I watch you fracture every moment,

knowing I cannot come with you

into that place beyond hope.

I’m holding it all together – in pain.

As my body aches with the routines of

morning, noon and the light on night

with pills, cups of tea and soundless TV,

when nothing but emptiness sits between us.

I’m holding it all together – just.

No-one knocks the door or calls anymore.

Because I’m coping with the care

they can rest assured and at ease, that

I’m holding it all together.

Donald Macaskill

This extended blog is the substance of a speech given to the EVH conference on the 17th May.

Thank you for being here. Thank you, too, for turning up to a conversation which if surveys are anything to go by, people either ignore or would frankly rather avoid.

I want to talk to you today about ageism, what it is and how it has developed over time; to consider its extent and pervasiveness in Scotland today, and what if anything can be done and is being done to address it.

Why is it important? – well for me: ageism is a stain on our collective soul.

We wrap it in polite assumptions and patronising jokes, in gentle mockery of forgetfulness, or in the economic rationalisation of “dependency ratios.” But make no mistake – when we speak of older people as if their worth is tied to productivity, when we design communities that exclude, when we limit aspirations rather than nurture them – we deny the dignity that belongs to every human being, at every age.

So, what do we mean by ageism?

Technically the term “ageism” was first coined in 1969 by Dr. Robert N. Butler, a pioneer in gerontology. He defined it as

‘the systematic stereotyping and discrimination against individuals based on their age, particularly targeting older adults.’

Butler’s observations highlighted how society often marginalises the elderly, viewing them as less capable or valuable.

But ageism and negative attitudes towards older age in particular pre-date Butler by a long way and can be seen across history, art and science – though intriguingly there is a real variety in the way in which diverse cultures and traditions view ageing and older age.

Ageism is not merely a social bias; it reflects deeper philosophical notions about value, productivity, and worth. Historically, Western societies have often equated worth with economic productivity, sidelining those who are retired or less active in the workforce. Even in my own lifetime and memory I am aware of attitudes which assumed that when someone retired their value was of limited societal benefit.

To be young is full of potential and contribution, ability and creativity, as we age and when we are old our potential is over, our contribution worthless, our abilities limited by frailty and our creativity mere a re-treading of our earlier abilities. We worship at the societal cult of youth and beauty.

Whether it is in literature or art we are all inheritors of negative stereotypes and beliefs about ageing and older age.

Ageism in Western art and literature has often reflected cultural biases that devalue aging and old age, especially when associated with decline, irrelevance, or grotesqueness. However, it can also reveal moments of reverence and wisdom. Here’s a cross-historical look at examples of ageism – both explicit and implicit – from classical antiquity to modern times:

As far back as the Greek philosophers such as Aristotle we see the stereotype of the elderly as overly cautious, suspicious, and cynical.

“They are cynical; that is, they always tend to put the worst construction upon everything.”

In the origins of classical theatre whether Greek or Roman we see elderly characters often mocked for their physical decline, sexual impotence, or irrelevance, playing comic or foolish roles. The Roman satirist Juvenal ridicules elderly women for clinging to youth or engaging in vanity.

“No one is young after forty, but men are sometimes delightful afterward.”

In political and civic life, it went even further – the best (or worst) example being in Ancient Sparta (c. 5th century BCE) where older people who were no longer able to serve in military roles were often sidelined and in a society that prized physical strength and youth older individuals who could no longer contribute to military life were seen as less valuable.

Things didn’t get much better as time went by – in the medieval allegory the Dance of Death / Danse Macabre we see older figures depicted as frail and near death, reinforcing the notion that aging is a prelude to judgment or decay. And the famous “Wife of Bath” is both empowered and mocked in Chaucer’s The Canterbury Tales (1387–1400) as she subverts norms but is also portrayed as sexually manipulative and “past her prime.”

Perhaps we reach our negative peak with good old Will – in his King Lear (1606) we see the eponymous character of the King descend into madness after relinquishing power which for Shakespeare was interpreted as a warning about the instability of old age.

“Age is unnecessary.” – King Lear

In the visual arts – say for instance in Caravaggio or Goya old age is frequently shown as grotesque or pitiable- highlighting sagging flesh, blindness, or senility- especially in contrast with youthful beauty.

Even the Enlightenment didn’t bring much enlightened positivity – with folks like Voltaire and Rousseau who often depict older people as resistant to progress or trapped in outdated thinking- reflecting the Enlightenment’s fetishisation of youth and rationality.

The Industrial Revolution (18th–19th century) saw a sharp reorientation in attitudes around age – as economies shifted from agrarian to industrial, older workers were pushed out of the workforce in favour of younger, faster, more “productive” labourers. (of course, including children!). Older people often became dependent on family or charity and were increasingly seen as economic burdens as capitalism began to consider worth not to age but contribution and physical economic capacity.

This reached its peak with the 19th Century Poor Laws which remained until the 1960s in Scotland at least as the attitudinal bedrock for the way in which we dealt with those who whether because of age or infirmity were not contributive.

The British Poor Laws institutionalised ageist policies by providing only minimal support to the elderly, who were often sent to workhouses if they had no family support. These institutions were harsh, with the elderly frequently treated with suspicion and disdain.

And the closer we get to our own cultural reference points the more embedded stereotypes around older age become. Who can forget the Dickens characters like Miss Havisham (Great Expectations) who represents old age as twisted by bitterness and isolation; or Scrooge’s transformation in A Christmas Carol which suggests redemption from the moral rigidity associated with age.

More horrific the Nazi regime developed and continued negative views of older age – and whilst we remember the attempted eradication of Jews, homosexuals, communists and many others we often have failed to talk about and recognise that the Nazi regime systematically devalued the lives of older adults, particularly those with disabilities. Under the T4 euthanasia programme, thousands of older people were forcibly sterilised or killed, deemed “unproductive” or “useless eaters.”

And closer to our own time the 20^th and 21^st cinematic representations not least from Hollywood offer persistent preference for youthful protagonists, with older characters (especially women) often portrayed as irrelevant, evil (the “crone” trope), or comic relief.

In terms of wider society whilst we may have closed the workhouses across the Western world, including the UK and US, mandatory retirement ages were introduced in the early 20^th Century, sometimes as early as 55. Effectively older people were excluded from economic participation regardless of their abilities or desires.

And even when in the latter part of the last century while pension systems were introduced to support older people, they often reinforced a stereotype of older adults as passive dependents, rather than active citizens with ongoing potential. Public policy tended to “manage” ageing, rather than celebrate it.

Time immemorial then we see some standard stereotypes and tropes around ageing and older age (and with very unsubtle gender biases)

• The Crone / Hag (e.g. fairy tales, Macbeth’s witches): aging woman as witchlike, manipulative, or grotesque
• The Foolish or Bitter Elder (e.g. Lear, Miss Havisham)
• The Discarded Elder (e.g. King Lear’s banishment)
• Idealisation of Youth (common in romantic and modernist visual art)
• Aging as Decline vs. Aging as Wisdom: The former dominates in mainstream narratives; the latter appears in select moral or spiritual texts.

Now all that is the ground in which the seed of ageism has flourished and spread.

All these historical examples show that ageism is not a new problem, but a structural issue shaped by economics, culture, and power. Today’s challenge is to unlearn these biases and create a world where ageing is seen not as decline, but as continuity, contribution, and worth.

Scotland

So, what about Scotland, after all we are the land of inclusivity, open welcome, and positive affirmation. Well not surprisingly we have not been immune to the challenges of ageism and arguably given our particular demographic profile some might suggest we have embedded both a policy and cultural ageism without robustly tackling it.

What is Scotland’s demography – well I suspect, many of you know this already.

Scotland’s 2022 Census reported over one million people aged 65 and over, surpassing the number of individuals under 15 by more than 250,000. This demographic shift underscores the importance of addressing ageism, especially as older individuals constitute a growing segment of the population.

We are an ageing population with a declining birth rate, and with a working age population which is becoming older and as a result less productive – as my sector – social care – knows only too well.

As of mid-2023, over one million people in Scotland are aged 65 and over, accounting for approximately 20.3% of the total population.  This marks a notable increase from 16% in 2001.

Projections indicate that this trend will continue. By mid-2047, the number of individuals aged 75 and over is expected to rise by around 341,300, representing a substantial growth in this age group.  This ageing is primarily due to longer life expectancies and declining birth rates. Since 2015, Scotland has recorded more deaths than births annually, a pattern projected to persist.

The demographic shift has significant implications. The dependency ratio – the proportion of individuals not in the workforce (under 16 and over pensionable age) compared to those of working age- is projected to increase from 60 per 100 in 2014 to 68 per 100 by 2033.  This suggests increased pressure on healthcare, social services, and economic support systems.

Addressing these challenges requires strategic planning, including policies that support healthy ageing, encourage workforce participation among older adults, and adapt public services to meet the needs of an older population.

But can this be down in a non-discriminatory and non-ageist manner – if it can we have potential to become a society that values ageing – that doesn’t see things as demographic time-bombs, or age tsunamis – but as potential, contribution and silver opportunity.

But is that our reality?

Well in truth my experience of Scottish culture, politics and public life is that if anything we are becoming more ageist and more discriminatory on the grounds of age and not less.

I would contend this position on several grounds.

Firstly, Employment Tribunal Awards: In the 2023/24 reporting period, there were 12 age discrimination cases in UK employment tribunals. The average award was £102,891, with a median of £86,349. Notably, six of these awards exceeded £50,000, indicating significant financial implications for employers found guilty of age discrimination.

Surveys suggest that many people either believe they have been or fear discrimination in seeking work if they are over the age of 55.

Secondly, in terms of growing incidents of hate, Age Scotland reports through its work that there are growing incidents of direct hate and harm being experienced by older persons. Following the implementation of the Hate Crime and Public Order (Scotland) Act on April 1, 2024, recorded hate crimes in Scotland rose by 63%. Approximately 300 of these were age-related, marking a significant increase and highlighting growing concerns about age-based prejudice.  You have to remember the recording of age as a characteristic in hate is new.

Further a survey by Age Scotland revealed that only 7% of respondents felt older people are represented positively in the media. The organisation emphasises that ageist portrayals contribute to negative societal attitudes and self-perceptions among older individuals.

Of even greater concern that media representation a recent survey by Age Scotland (in late 2021) reported that a significant number of older Scots have reported experiencing ageism. The survey found that more than a third of respondents (36%) felt they were made to feel a burden to society. Additionally, 34% said that life was getting worse for older people in Scotland. One in five (21%) felt valued by society. The survey also revealed that 12% of respondents had experienced age discrimination in the workplace.

Lastly, my own personal experience of the pandemic and our national, governmental response is one that suggests that age discrimination was not far from the table, even if it was subtle, and as a backdrop rather than in the foreground.

The evidence heard to date before both the UKL and Scottish Covid Inquiries would at least give us pause for thought.

During the pandemic, many countries, including the UK, prioritised younger populations for hospital resources and ICU beds. That is – for me at least – an inescapable truth not least in the ‘clearing of our hospitals.’ And in the development of highly questionable and unethical emergency clinical decision tools and approaches. In some instances, blanket DNACPR (Do Not Attempt CPR) orders were applied to older care home residents without consent. Certainly, that has been the view of experts such as the United Nations.

More broadly I think ageism and age discrimination is evidentially rife in our societal failure to prioritise social care.

These examples illustrate the multifaceted nature of ageism in Scotland, affecting employment, media, legal systems, and societal attitudes. Addressing these challenges requires concerted efforts across sectors to promote inclusivity and respect for older individuals.

So what can be done?

In Scotland Age Scotland and other organisations including my own has advocated for the establishment of a Commissioner for Older People in Scotland. This role would aim to amplify older individuals’ voices, ensure their rights are protected, and address issues such as ageism, access to services, and digital exclusion.

At the United Nations in Geneva following a significant decision this April, work has started on the creation of a Convention on the Rights of Older Persons, but this will take a considerable period of time.

But I think we can do more …

This is not just about challenging obvious prejudice – it’s about unlearning deeply embedded assumptions about value, beauty, purpose, and potential.

We can and must do more to combat ageism effectively, especially within the context of Scottish society. Scotland needs a renewed, bold and unapologetically ambitious strategy for positive and active ageing. One that is not a subsection of health and social care, but a whole-of-government, whole-of-society commitment.

Let me offer a few extra steps we must take if we are serious:

Redesigning communities through the lens of age inclusion

This means accessible transport, intergenerational housing, safe public spaces, and services that work for everyone from 8 to 88. This is not utopian — it is simply just.

Education and Awareness

We need to integrate discussions about aging and ageism into educational curricula to foster understanding from a young age. Intergenerational work is critical and a benefit to all.

Policy Reform

We need to implement policies that protect against age-based discrimination in employment, healthcare, and social services. And not just have the policies and legislation but to robustly enact them. We can start by auditing all existing policies and practices – ideally through an independent Commissioner.

Reimagining work and contribution

We must challenge retirement as the end of value. Many older people want – and need – to continue working, mentoring, creating. Let us support flexible models of work, lifelong learning, and volunteering that respect the diversity of older lives and don’t just let us continue to play at this.

Community Engagement

We need to encourage intergenerational programmes that promote mutual respect and understanding between age groups. And not just encourage resource and fund because so many third sector organisations are being stripped of cash.

Media Representation:

And critically we need to advocate for diverse and accurate portrayals of older adults in media to challenge prevailing stereotypes.

Tackling digital exclusion as a rights issue

The digital divide is not just a gap in access – it is a denial of participation. Every time we design a service that assumes digital literacy, we risk leaving people behind. Inclusion must be designed in from the start.

All of this will take political will, social courage, and cultural change.

But most of all, it will take a radical reorientation of our values — one that refuses to tolerate systems that reduce people to years, needs, or costs.

You see, I believe that how we treat our elders is not just a social policy issue – it is a measure of our national character.

Do we see older people as burdens to be managed?

Or as citizens to be honoured, included, and celebrated?

That is the question at the heart of ageism.

We need a Scottish society where ageing is not something to be endured but embraced. Where care is not a transaction, but a relationship. Where every life is seen as whole, from the first breath to the last.

And what about the housing sector? How age blind is the sector? Are we build to enable accessibility or building to perceived demographic demand? We should remember the power of the silver pound, and the reality that the generation of tomorrow – our older generation will not sit down and accept the limitations of others upon their lives. They will – I have every confidence – act and demand, work and achieve equal treatment.

It is time to celebrate age – and I intend to grow old disgracefully but with dignity

Dignity has no use-by date.

It does not expire when we retire.

It does not fade with memory.

It is not conditional on mobility, nor appearance, nor the capacity to contribute to GDP.

It is rooted in being human — and that is enough.

Donald Macaskill

Photo by Ksenia Emelianchik on Unsplash