The following extended blog is the substance of an address delivered to the Scottish Partnership for Palliative Care conference on the 13th November.

I want to begin not with policy, nor with strategy, not even with the practice of social care itself. I want to begin with a poem.

It is for me one of the great poems of the twentieth century, written in Gaelic, by Sorley MacLean who was born on the island of Raasay just off Skye. His work has been credited with restoring Gaelic tradition to its proper place and reinvigorating and modernising the Gaelic language.

His poem Hallaig, published in 1954, achieved an almost “cult like status” outside Gaelic-speaking circles for its supernatural representation of a village depopulated in the Highland Clearances. For those like me who had grown up with grandparents who were the children of the thousands who were ‘cleared’ off their land to make way for sheep and the profits of landowners, his words echo a truth of painfulness.

Hallaig is a poem about place, about people, about presence and absence. A poem that carries both lament and hope, both grief and rootedness.

In translation part of it reads:
“Time, the deer, is in the wood of Hallaig.
The shadow of the birch is in Hallaig,
and the trees are standing tall
where people once stood.”

When you walk into Hallaig, the cleared village on Raasay, you see no houses, no children, no hearth smoke. The people are gone. And yet in MacLean’s vision, they are still there. Their memory abides in the birch trees, in the glen, in the silence that is alive with absence.

I want to take Hallaig as our guide this morning. For in considering what social care contributes to palliative and end of life care I want to start by saying that I believe it is precisely that: presence in absence, the rootedness of memory, the holding of community when it seems no longer there.

Right at the start it is useful to say what social care is

One definition I work with is this:

“The enabling of those who require support or care to achieve their full citizenship as independent and autonomous individuals. It involves the fostering of contribution, the achievement of potential, the nurturing of belonging to enable the individual person to flourish.”

It is not about maintenance but about life in all its fulness.

It is delivered by around 212,00 people that’s over 50, 000 more than in the NHS

It is witnessed in care homes, in people’s own homes, in housing support across the country.

We do not, in Scotland, like to talk of death. We do not, if truth be told, like to talk of decline, of diminishment, of ageing, of endings.

We are a nation of euphemisms.
“She’s passed on.”
“He’s away.”
“She’s no longer with us.”

We avert our eyes. We walk on the other side of the road.

Yet absence, I believe, is not void. Absence can echo. It can hum with memory. The room of a dying person is heavy with memory, with love, with stories still untold.

Death is not avoidance. Death is presence. It is as real as breath. It is as much part of life as birth itself.

I met Mairi in a care home on Skye. She was a woman with silver hair, her mind drifting like mist – but her hands knew the old Hebridean psalm tunes. Her carer, Eilidh, sang with her each evening. When Mairi could no longer recall the words, Eilidh sang to her, and Mairi’s eyes filled. Even as memory slipped, presence remained. In that moment, social care was a sanctuary. The birch trees, living memory.

MacLean’s Hallaig captures the paradox – that absence can be full of presence. That a glen emptied of its people can still echo with their laughter, their footsteps, their lives.

And that is the role of social care in palliative and end-of-life work.

We are the companions of presence. We are those who stay when others turn away. We are those who sit in silence when there are no more words, those who hold a hand when there is no more cure, those who listen to the laboured breath and still hear the human story.

I have seen in care homes across Scotland what I can only call sacrament. A worker, exhausted at the end of a shift, bending down to kiss the forehead of a woman who is dying, whispering in her ear, “You are not alone…You are not alone.”

I have watched in a cramped tenement flat a home carer arrive with a flask of soup, not just to nourish but to bless. To remind a frail man that he is still part of a circle of care, still someone, still himself.

In those moments, social care is Hallaig. We are the birch trees. We are the presence that stands where absence seems overwhelming.

In places and at times when there are no definitive answers to profound questions the role of the carer is like the potter with raw clay – searching for the story inside, for truth to find its shape, for the moment to appear.

I think this is especially the case in the care of those who are very old and those living their end days with dementias.

I am reminded in that regard of the words of another poet David Whyte, who writes:

“The only choice we have as we mature is how we inhabit our vulnerability, how we become larger and more courageous and more compassionate through our intimacy with disappearance.”

Care, in all its forms, not least social care, – is an intimacy with disappearance. It is the daily act of standing beside someone as they change, decline, recover, or die. It is the art of presence in the face of absence. And it is in this space – this vulnerable, sacred space – that care is being created.

It is important, I think, to say something that is not always heard in the public square.

Palliative care is not only about hospices. It is not only about hospitals. It is not only about the skilled interventions of doctors and nurses, invaluable and irreplaceable though those are.

Palliative care is also, distinctively, deeply, profoundly, about social care.

What makes social care distinctive in the work of dying?

It is not equipment, though we sometimes bring that.
It is not medicine, though we often support its use.
I think it is relationship, it is ordinariness, it is continuity – all of which are about enabling presence in absence.

The carer who has washed your hair for two years is the carer who knows how to wash it when you are dying.
The support worker who has shared your laughter at Christmas is the one who knows how to comfort you when you face your final days.
The care home manager who has phoned your daughter every week is the one who phones her when you have only days to live.

This is not incidental. This is the very heart of what makes social care distinctive.

We do not walk into someone’s life at the eleventh hour. We walk alongside them through the long days of ageing, through the seasons of frailty, through the slow diminishment of memory. And when the time of dying comes, we are already there.

There is, in social care, an intimacy, an ordinariness, that is profoundly palliative.

It is in the cup of tea.
It is in the blanket tucked round legs.
It is in the song sung softly, the prayer whispered, the silence held.

Care homes at their best are communities of memory. They are places where life is lived until the very last breath. They are places where birthdays are celebrated even when candles are hard to blow out, where Christmas trees sparkle even when vision fades, where the ordinary rhythms of life continue right up to the threshold of death.

Care homes are not passive spaces – they are living, breathing communities.

At an Edinburgh care home, the staff celebrated Hamish’s 100th birthday with cake, accordion music, and stories. A month later, Hamish quietly passed away, mid-dance. No medical machinery, just life flowing to its close, and presence, still.

Home care is even more intimate. To die at home, with your own curtains, your own wallpaper, your own cat curled on the bed – this is what many people long for. And it is social care that makes that possible. It is the carer who comes at seven in the morning, at midnight, at dawn, who makes that choice real, not just theoretical.

In a Fife care home, a man called George loved fish suppers. Every Friday, for years, staff brought in a bag of chips from the local chippy. Even when swallowing grew difficult, they still brought the chips. They placed them near his bed, so he could smell the vinegar and salt, the comfort of familiarity. George died one Friday evening, with that scent in the air.

Medical charts or care records did not record that moment. But it was a palliative act – ordinary, rooted, profoundly human.

This is what the national palliative care Strategy calls “timely, co-ordinated care based on what matters.” But to me, it is simply social care – ordinary love made visible.

In all these moments, it’s not just what we do – it’s who we are. Social care brings ordinariness, relationship, continuity.

The new Scottish Government strategy, Palliative Care Matters for All, affirms a vision:

‘By 2030, everyone in Scotland, adults and children, should have equitable access to well-coordinated, timely, and high-quality palliative care, care around dying, and bereavement support based on what matters to them – including families and carers.’

The strategy also calls for Scotland to be a place where communities support each other, talking openly about serious illness, planning, dying, and bereavement. This is our calling: to turn avoidance into conversation, absence into presence.

For these ambitions to be realised in social care, workers must be seen, trained, guided, supported – and the lived, ordinary moments honoured in policy as much as the specialised ones.

When people ask me, “What does social care do in palliative care?” I answer: it makes dying human. It makes dying ordinary. It makes dying part of life.

But let us be clear: this is not just sentiment. It is not just good practice. It is a matter of human rights.

For me to die well should not just be a privilege for the few.
It is a right for all.

The right to dignity does not end when disease progresses.
The right to autonomy does not vanish when memory falters.
The right to participation does not fade when speech is lost.

As most of us in this room know the majority of people die not in hospitals, not in hospices, but in care homes and in their own homes.

Most palliative care in Scotland is delivered through social care.

• 89% of people in Scotland will need palliative care.
• Over 30,000 frail older people receive care at home each week.
• Most people in care homes are in their last 18 months of life.

And a critical part of that social care contribution is the work of unpaid carers who are the Invisible Backbone

They are the mothers, fathers, daughters, sons, neighbours, and friends who provide the majority of palliative care in Scotland – not for pay, not for recognition, but out of love and duty.

The 2025 Carers Update estimates that there are 694,000 unpaid carers in Scotland, including 27,000 young carers.

Unpaid carers carry the weight of love and loss, often in silence. They need more than our gratitude – they need our support, our policy, our resources.

And yet – and yet –  policy, funding, public discourse all too often overlook the reality of both paid and unpaid social care and support.

Let us not enshrine policy without teeth. The Strategy must be backed by funding, staffing, equity. The ambition of the strategy is right. But ambition without investment is poetry without music.

Unless palliative care in social care is resourced, unless the workforce is valued, unless communities are engaged, then those words risk becoming another uninhabited village, another Hallaig of policy – present in name, absent in reality.

This is not simply unfair. It is unjust. It is a violation of rights.

And so we must ask: how do we make sure that Isa or George, are not exceptions, but expectations?

The trees of Hallaig remind us: absence does not mean invisibility. The people are still there, even when the state forgets them. And in social care, we stand with them. We make them visible.

Of course, it is not easy.

Our sector is stretched. Staff are underpaid, undervalued, exhausted. Recruitment is hard. Retention is harder.

We cannot talk about a “dignified death” while those who enable that dignity are themselves denied a dignified wage.

And we also have as everyone in this room knows only too well to acknowledge that death itself is demanding. To sit with dying day after day takes a toll on the soul. To lose people you have loved – and make no mistake, carers do love – is to carry grief upon grief.

Yet despite the hardness I also see hope.

In Inverness, a care home created a “memory tree” in its hallway. Every time a resident died, a leaf with their name was hung upon it. Families came back months later to see their loved one’s leaf still there, still part of community.

In Dundee, a team of carers took it upon themselves to bake scones every Saturday morning for a dying woman who had baked all her life. Even when she could no longer eat them, they baked. They filled the house with the smell of her past. That was hope in flour and butter.

In my own island of Skye, I have taken part in many a vigil. Neighbours gathered outside a croft as someone lay dying inside. They sang psalms in the dark, their voices carrying through the wind. Social care and community entwined, ancient and modern, grief and love in song.

This is our hope – not abstract, but real, rooted, ordinary.

I see hope despite the hardness of days.

I see it in the resilience of staff who turn up every day, who walk into rooms heavy with breath and do not flinch.

I see it in the creativity of care homes that hold vigils, that sing, that weep, that honour the dead with dignity.

I see it in the rituals of remembrance – the photographs, the memory books, the trees planted, the candles lit.

In our Gaelic and Scottish traditions, we are not strangers to grief. We have keened, we have sung laments, we have told stories round the fire. We have known how to hold loss as community.

Social care, I believe, continues that tradition.

We are the keeners of today.

We are the singers of lament in the corridors of care homes.

We are the holders of memory in the tenement flats of Glasgow, in the crofts of Skye, in the bungalows of Dundee.

And there is hope in that.

For a Scotland that can face death is a Scotland that can face life. A Scotland that can accompany the dying is a Scotland that will value the living.

In closing let me turn again to poetry, for it is in poetry that we find the language for what is hardest to say.

Sorley MacLean, in Hallaig, reminds us:

That is what social care does.

We make the dead present in memory.

We accompany the living into death with dignity.

We stand as trees in the glen of absence, rooted, ordinary, beautiful, enduring.

A poem:

Beneath the Trees

Beneath the trees, where birch and rowan speak to the wind,

the memory of people flows like the sound of water—

gentle as peat, strong as oak roots

holding the earth together.

Social care is the quiet road,

threading through the glen of living and leaving,

where human hands become branches,

offering shade, shelter,

and courage when the light draws to its close.

Palliative care is not an ending,

but a circle drawn in kindness—

a hearth of listening,

where pain is met with presence,

and loneliness with love.

Let us be the forest,

deep and interwoven,

where no one dies alone,

and where every breath is honoured

as part of the song of the hills.

Let us never forget:

Life is a forest, and every leaf matters.

Donald Macaskill

Photo by Ann on Unsplash

As the UK Chancellor prepares to deliver the Budget next Wednesday, Scotland stands at a crossroads. For too long, social care has been treated as an afterthought or as the underling of the NHS, yet it underpins everything we value: dignity in later life, support for unpaid carers, and the ability for people to live independently and participate fully in society.

This is not a marginal issue. It is the infrastructure of compassion that sustains our communities. And right now, that infrastructure is collapsing.

Scotland’s social care system is at breaking point. Workforce shortages, rising costs, and chronic underfunding have created a perfect storm.

In rural areas like the Highlands, geography compounds the crisis: delayed discharges cost millions, care homes close, and families face heartbreak as loved ones are sent hundreds of miles away because there is simply nowhere local to go. This is not dignity rather it is systemic failure.

Audit Scotland has warned repeatedly that urgent action is needed to change how services are delivered. Yet despite record allocations on paper, the reality is stark: councils and health and social care partnerships are in year debt to the region of around £500 million. Providers are closing. Skilled workers are leaving because they cannot afford to stay in a profession they love.

When I think of the two main sectors that my membership comprises both are on their knees in the majority of locations.

Homecare is the backbone of independence, but it is collapsing under financial strain. The latest Minimum Price for Homecare in Scotland, as calculated by the Homecare Association for the financial year 2025–2026, is £32.88 per hour. No Scottish council meets the minimum price. Notice it’s a minimum price not a fair price!

To add insult to injury providers report late payments averaging £300,000 per organisation, threatening viability and continuity of care. And the obscenest occurrence is the explosion in 15-minute visits when we were supposed to be seeing the end of this practice which is an absolute assault on dignity.

Every hour of care at home is an investment in human flourishing. It prevents hospital admissions, reduces loneliness, and sustains wellbeing. Yet this lifeline is fraying if not already broken.

The independent care home sector provides 86% of all registered places in Scotland yet has seen a 34% decrease in residents since 2014. Over the past decade, 476 care homes have closed or changed hands, sometimes forcing families to travel 100 miles or more to visit loved ones. This is not just inconvenient, it is cruel. Any fair analysis shows the £1,027 per resident per week for intensive 24/7 nursing residential care is a good £500-£1000 short of the true price of dignified care and even that ties return or profit to 4%, way below what most economists argue is needed to keep a business, be it charitable, not for profit or private going.

Empty beds today mean closures tomorrow, and every closure strips communities of choice and dignity.

Delayed discharge is the most visible symptom of a whole system paralysis. More than five million bed days have been lost since 2015 at a cost of £1.5 billion. Hospitals are gridlocked because social care is starved of funds.

But the invisible cost is what really matters. It’s the thousands who are waiting up to 18 weeks to be assessed for the care they need; it’s the hundreds who die without the dignified end of life care they deserve; it’s the burnt out and exhausted thousands of family and friend carers who are at their wits end with fatigue and emptiness.

And just in case you think I’m engaging in hyperbole and exaggeration – the avoidance critique of those made uncomfortable by the raw truth of political failure, others are in agreement.

COSLA, the representative body of local government in Scotland, has issued a clear warning: without fair and sustainable funding, we risk the viability of services that people rely on every single day. Their manifesto calls for an additional £750 million investment in social care and an end to 15-minute visits in homecare.

More immediately they have also called for the urgent reconvening of the Financial Viability Response Group of which providers through Scottish Care and CCPS sat on at the start of the year and which in April offered a truthful report with recommendations to the Cabinet Secretary.

Councillor Paul Kelly put it bluntly:

“Local Government cannot do this alone. Demand is increasing, costs are rising, and the workforce is under immense strain.”

Yet we have been faced with silence from the Scottish Government other than a statement to address winter pressures by giving £20 million to NHS Boards to address ‘social care’ needs. An allocation not to local authorities or HSCPs but to the sacrosanct NHS.

Scottish Care has consistently argued for a budget that values social care not one that kills reassurance and forces closures. As I said recently, people are dying because they cannot get the social care they need. This is not hyperbole; it is happening now. Services are closing, staff are being made redundant, and communities are losing lifelines.

The UK Government must also shoulder responsibility. Immigration policy changes such as scrapping social care visas, raising salary thresholds, and increasing sponsorship costs are reckless and inhumane. In rural Scotland, internationally recruited workers make up more than 25% of the workforce. Removing this lifeline will devastate communities and put lives at risk.

Both governments must act decisively. The UK Government needs to reverse damaging immigration changes, exempt social care from National Insurance hikes, and deliver Barnett consequentials that prioritise care. The Scottish Government needs to commit to COSLA’s £750m ask, deliver multi-year funding agreements, and accelerate reform that values workforce and community-led care models.

This is not about party politics – it is about people. Every delay deepens the crisis. Every cut costs lives.

Social care is not a drain on resources; it is an investment in humanity. It is the infrastructure of compassion that sustains our communities. As we await the Budget, let us demand a budget that cares; a budget that restores dignity, strengthens the workforce, and ensures that no one in Scotland is left without the support they need.

I appeal to our political leaders to stop the rhetoric and start the rescue.

To the public I say, raise your voice for those who cannot.

Social care is the foundation of a fair Scotland. If we fail to act now, we will not just lose services but inevitably we will lose lives, communities, and trust in the very idea of care. “Social care is not a cost – it is the currency of compassion.”

We cannot afford another winter of reactive measures. We cannot afford to lose more care homes, more workers, more trust. The UK Budget must deliver for social care. The Scottish Government must match ambition with action.

This is not just about funding. It is about the kind of country we want to be. One that values its elders, supports its carers, and builds communities of care rooted in dignity, belonging, and hope.

This Saturday, before the Budget, let us make one message clear: Scotland demands a budget that cares. Nothing less will do.

Donald Macaskill

When I was growing up, there were a few select books that appeared every year with faithful regularity on my grandmother’s bedside table. One of them which is still going strong with its distinctive purple cover was The Friendship Book.

First published in 1938 by D.C. Thomson & Co., it is an annual publication best known for its gentle reflections, uplifting prose, and moral wisdom. It offers a short thought, poem, or inspirational reflection for each day of the year. It is a book that doesn’t shout, but whispers comfort and companionship.

I once asked my grandmother how it was possible to have something new and different to say about friendship every day of every year. She replied, with a smile, that true friendship is a conversation that never finishes.

How much truth was there in that sentiment. Because in the world of social care, especially for older people, friendship is not a seasonal sentiment instead it is a daily necessity. It is the thread that binds together lives that have been frayed by loss, change, and time.

As we mark Book Week Scotland 2025, with its theme of Friendship, we are invited to reflect not only on the stories we read but on the stories we live. For those of us who work in social care, and for the thousands who receive it, friendship is not a luxury rather it is a lifeline.

There is a somewhat perverse irony that we live in an age when people have more opportunities than ever to make friends, thanks to technology, global mobility, and social networks. Digital platforms, online communities, and instant communication make it easy to connect with others across distances and cultures. People who might once have been isolated because of geography, disability, or social circumstances can now find like-minded communities online.

However, research suggests that many people today actually feel lonelier and have fewer close friendships than in previous generations. Social media can create connections but also foster superficial interactions rather than deep, enduring friendships. The way we live our lives, with busyness, frequent moving, and remote work, can make it harder to maintain long-term, in-person relationships. And culturally, former community structures like local clubs, churches, or neighbourhood groups that once supported friendship networks are often less central in people’s lives.

So while the potential for making friends is greater than ever, the quality and depth of those friendships may not always be as strong as in earlier, more community-based times. But the truth remains that friendship is intrinsic and fundamental to living in community with others, no less so than in older age.

Friendship in older age is not just a social nicety we know it also to be it a psychological necessity. Studies have shown that older adults with strong social networks experience lower rates of depression and anxiety; they have improved cognitive function and memory retention, possess greater resilience in the face of illness or bereavement and all in all have enhanced physical health, including lower blood pressure and better sleep.

These are not abstract benefits. They are real, lived experiences. I remember speaking to a woman in a sheltered housing complex who said:

“I’m 83, and I’ve just made a new friend. We walk together, we talk about books, and we laugh. I didn’t think I’d feel this alive again.”

Friendship is woven into the fabric of being in community. I’m struck by this every time I visit my family in the islands, where belonging to place and people still shapes lives. There, friendship is woven into the fabric of care. It is found in community-led initiatives where neighbours become carers, and where the boundaries between formal and informal support blur into something more humane.

In urban Scotland, friendship is the antidote to isolation. It is the volunteer who visits every Thursday, the care worker who knows the names of grandchildren, the fellow resident who shares memories of wartime Glasgow. These relationships are not incidental; they are central to wellbeing.

Yet, too often, our systems fail to recognise the value of these connections. We measure minutes and tasks, but not the moments of meaning. We audit medication, but not the comfort of companionship. If we are to renew social care in Scotland, we must place friendship at its heart.

But this is, after all, Book Week and we must affirm that books have always been companions. For older people, especially those living with dementia or facing bereavement, stories can be bridges to memory, identity, and connection.

I have sat with individuals who, though struggling to recall the present, can recite poetry from childhood or recount the plot of a novel read decades ago. Literature becomes a lifeline to the self.

In care homes across Scotland, reading groups are springing up not just as activities, but as communities. Residents read aloud, discuss characters, and share their own stories. These are spaces where friendship is nurtured through narrative.

A gentleman in one home told me:

“I never thought I’d read again. My eyesight’s poor and my hands shake. But every Tuesday, we gather and someone reads to us. It’s like being back in school but better. We laugh, we argue about the endings, and we remember who we were.”

Books also offer a bridge across generations. Grandchildren reading to grandparents, carers sharing poetry, volunteers bringing stories to life— all of these moments create connection.

The Scottish Book Trust’s annual publication, Scotland’s Stories: Friendship, is a testament to this. It gathers voices from across the country, including those often unheard such as older people, carers, those living in rural isolation. It reminds us that storytelling is not the preserve of the young or the literary elite. It belongs to all of us.

More positively, innovation in care technology is opening new doors for friendship. Digital storytelling platforms, virtual book clubs, and reminiscence apps are helping older people stay connected, even when mobility or geography pose challenges.

But technology must serve humanity, not replace it. The warmth of a shared story cannot be coded. A virtual hug is not the same as a hand held in silence.

As we look to the future, we must ask: how do we design care systems that foster friendship? How do we train carers not just in clinical skills but in the art of listening? How do we ensure that every older person in Scotland has the opportunity to be known, to be heard, and to belong?

Let me end with the words of Peter Mackay, Scotland’s Makar, whose work often explores the intersections of language, memory, and connection. In his poem Anamnesis, he writes:

“We are made of stories, stitched into skin,

Of voices that echo long after the din.

In the hush of a room, in the turn of a page,

Friendship endures, defying age.”

This Book Week Scotland, let us celebrate friendship not only in fiction but in the lived realities of those who depend on care. Let us honour the storytellers in our care homes, the poets in our communities, and the quiet revolutionaries who build connection in the face of loneliness.

Because in the end, it is friendship that makes us human.

Donald Macaskill

Photo by Sabinevanerp

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Coughlin is clear:

“Technology without empathy is just engineering.”

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

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

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

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

As Coughlin writes:

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

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

 

Donald Macaskill

 

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

So what can be done ?

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

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

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

I want to suggest several actions:

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

1.

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

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

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

A Highland Weighting scheme would also recognise:

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

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

There are some key components

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

The London weighting scheme has shown that:

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

Applying these lessons to the Highlands would require:

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

Other countries do this:

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

Key Features:

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

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

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

Key Features:

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

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

2. Community led-models of homecare.

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

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

Again, there are clear international lessons:

Canada has adopted an Integrated Rural Home Care model

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

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

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

3.

Care homes must also evolve.

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

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

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

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

4.

Flexible regulatory and registration arrangements for workers and organisations.

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

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

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

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

To succeed it needs regulatory change and flexibility.

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

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

5.

Investment in co-ordinated digital infrastructure

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

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

Conclusion

We are at a turning point.

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

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

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

Donald Macaskill

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Stroke

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

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

her hand cold-numb below the eiderdown…

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

And still my mother didn’t answer.

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

Donald Macaskill

Today, October 18, is World Menopause Day.

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

But awareness is only the beginning.

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

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

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

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

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

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

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

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

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

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

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

This is not marginal. It is central.

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

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

She Loves Me, She Loves Me Not

She loves me.

By day she sits, quietly, by my side.

My night cool and restful.

She loves me not.

She laughs mockingly in my face.

And it burns.

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

I’m a rabbit caught in the headlights.

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

She’s packed away my self-esteem.

My courage fails me.

Meltdown.

The night brings no solace.

Her furnace stoked.

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

I’m stuck on repeat.

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

That my hormones will, eventually, settle down.

Bring on that day.

 

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

 

Donald Macaskill

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Remember

Christina Rossetti

 

Remember me when I am gone away,

Gone far away into the silent land;

When you can no more hold me by the hand,

Nor I half turn to go yet turning stay.

 

Remember me when no more day by day

You tell me of our future that you planned:

Only remember me; you understand

It will be late to counsel then or pray.

 

Yet if you should forget me for a while

And afterwards remember, do not grieve:

For if the darkness and corruption leave

A vestige of the thoughts that once I had,

Better by far you should forget and smile

Than that you should remember and be sad.

 

Donald Macaskill

 

Photo by The Good Funeral Guide on Unsplash

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Realism tells us that social care is at breaking point.

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

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

That is the hope we must build upon.

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

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

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

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

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

Reform means:

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

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

As the poet Hugh MacDiarmid once cried:

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

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

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

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

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

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

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

Implementation is where aspiration meets accountancy.

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

Implementation requires:

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

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

Let me put it in five imperatives:

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

I want to finish as I started with a story.

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

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

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

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

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

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

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

Donald Macaskill