There is never a dull moment in the world of social care in Scotland. In the past week we have ongoing debate about the National Care Service culminating in the decision of the Scottish Government to pause the Bill Stage 2 process and to return to the matter in 2025. This decision has been met by some who think it means the end of the Bill and by others who wish it did, and yet others who are both confused and disappointed.

I mention all this because yesterday was the Scottish Care Care Home conference. This annual event brought together care home providers, managers and workers, together with other stakeholders and partners from across the country. It was also an opportunity to hear from some of our political leaders, including the Cabinet Secretary Neil Gray, about their position on a whole range of issues, not least the National Care Service.

However, for most of those there the number one issue was not the future shape of social care (however critical that is) but whether they would be around to see it. Yesterday Scottish Care published a summary of some of our latest consultation with our members about the implications of the Westminster Labour Government’s intention to increase the National Insurance threshold and rates. Our research indicated that of those who responded to a survey in the past week, nearly half (48%) of care home and homecare organisations noted the very real possibility of service closure as a result of this increase.

In our media statement I said that:

“These additional pressures on social care providers created by the UK Budget announcement are unworkable in the current climate and a solution, either through exemption or funding, must be found in order for the social care sector to be sustained. Scottish Care is incredibly alarmed at the figures presented in our survey, not least around service closures, with many providers indicating that this may very well be the straw that breaks the camel’s back. It is no exaggeration to say we will lose swathes of social care provision in Scotland unless urgent, practical and resource-based solutions are progressed for the sector. If not, the impact on individuals, communities and public services will be catastrophic.”

It was in the context of such a troubling background that together with my colleague, Scottish Care’s Deputy CEO, Karen Hedge we ended the conference by focussing on the Four V’s which lie at the heart of Scottish Care’s recent Strategy document. What follows is a summary of what we shared:

Visible​

Social Care that works for Scotland ​

In order to move forward you need to know who you are …

Scottish Care is essentially a membership organisation – we represent the greatest diversity and range of providers of social care in Scotland indeed probably in Europe – from care home to homecare, housing support to respite support. From small single operators to large corporate organisations; from rural to remote and urban to town.

We are an organisation driven by social values. We aim to ensure that social care in Scotland is not only sustainable but also exemplary, reflecting the high standards and compassionate care that our communities deserve.

The problem is that a lot of people do not know what social care is – we have got to the stage of it being seen as the release valve for the NHS on the one hand (not least around delayed discharge and avoidable admission) or as a set of services which is about maintenance and keeping people safe – it is so much more.

It is about flourishing and thriving – about citizenship and contribution, it is about challenging the discrimination of age and the limitation of conditions such as dementia.

social care is rather:

‘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 time for social care and care homes to be seen for what they are  – contributors and not costs, enablers of life and not limiters of freedom, places of thriving lives and not ante-rooms of the end days.

As a society we need to shout loudly about the brilliance of compassion and the dedication of our care homes staff and managers in the delivery of a society which values all.

We are here to build the possibility of a society that truly values care, and walks the talk of the rhetoric of priority.

Viable

Scottish Care also published yesterday our report on Ethical Commissioning which states clearly that we need to radically reconceive the way in which we commission and contract care services into a model which embeds human rights at its heart. It centres its focus on rights, respect and redistribution. People deserve high quality social care and support focussed upon human rights

Social Care is experiencing an increase in demand at the same time as a decrease in resource and it remains a net contributor to the economy. It is time to think differently and sustainably.

We need to start thinking about the potential for social care to be an economic and societal driver rather than using the language and mindset of cost and drain.  We need to focus on human rights – work collaboratively across the health and social care system in the preventative space and beyond, to make sure that people can live with autonomy for longer.

This all requires that we approach each other with mutual regard and transparency, creating trust in a system built upon robust cost of care modelling and funding this by reducing duplication and bureaucracy, bridging the implementation gap through a redistribution of funds.

We also need to support our amazing social care workforce through the implementation of Fair Work principles and sectoral bargaining, but we need to do this in a planned way with appropriate procurement measures. The implication and implementation of the Employee Rights Bill and the UK Budget have to be recognised both at Scottish and UK level. Almost half of our members responded to a survey on the budget saying that they may not be viable with the changes to National Insurance contributions alone, if these are not carried through into funding.

What we have stated before of net-zero is true still of commissioning:

“Many of the concerns circle back to the long-standing issue of insufficient funding available in the sector and the undervaluing of social care. Changing mindsets to focus on sustainability in the commissioning and procurement processes would be beneficial to implementing long-term change”

We no longer have a National Care Home Contract which is fit for purpose ands indeed the financial gap between true cost and public funding is between £4-500. Such a contract limits and the moral step away from funding the true cost of care cannot be excused.

​Valued​

At some point, everyone in Scotland is likely to experience care and support either directly themselves or indirectly for their loved ones.

It’s time to celebrate social care, a sector that makes a difference every day for the people of Scotland, whether you access, work in or provide it.

Despite the shelved human rights bill, we put human rights at the front and centre of our work, we know that value lies in people, not process but we need to do more to address discrimination in our society. Discrimination in our legislation which excludes older people living in care homes from access to self-directed support,  discrimination which has become so pervasive against older people we do not even notice it is there.

And societal discrimination in the form of microaggressions which for instance maintain that it’s women’s work, worthy only of a living wage, rather than a professional wage for professionally qualified and regulated individuals. That it’s women’s work, thinking which a recent study as part of IMPACT showed that deters men from considering a role in social care because they are too worried what their family might say thus perpetuating the myth.

Everyone in this room knows the worth of social care and support through the significant contribution it makes to society and our economy. Through the difference that it makes to our lives and in the measurement of humanity.

It’s time we broke through those barriers and set things right. It’s time for a care revolution to bring us social care that works for Scotland.

​Visionary​

All of us recognise that the seeds of change are rooted in the present moment, that the future is not an alien country but one we must all be citizens of. We can never stand still, we must always be re-imagining our today in a new direction.

So that is why Scottish Care is continually committed to asking the hard questions – what will a care home need to look like? How do we make services and support truly person-led with the citizen in charge and our services and staff there to enable them to direct their living?

That’s why technology and digital solutions and the emerging role of Ai are not a fad or a distraction but central and critical for the delivery of quality and rights-based care and support.

That’s why we will use design approaches to work with a range of stakeholders so that the people in this room and those who use services and support in care homes are at the forefront of coming up with a vision of tomorrow.

Whether through our work on data or research and policy we will continue to listen to the best the world of aged care has to offer in all corners of our globe, bring insights into this place and help to re-shape plans and possibilities into realities and revolution.

An American actor once said:

“Tomorrow is the most important thing in life. Comes into us at midnight very clean. It’s perfect when it arrives and puts itself in our hands.”

We all of us have the potential to create a vision of the possible for social care in Scotland, we can work together from all political standpoints to put aside short term self-interest and partisan positioning and identify what we can agree on and re-shape that tomorrow.

Tomorrow is fresh and full of possibility, if we dare to allow all that stops us from working together to be set aside.

Donald Macaskill

Karen Hedge

Photo from Joshua Sortino from Unsplash

In a previous blog I mentioned that I had had the privilege of visiting Australia where I had the opportunity to meet with and discuss the challenges of delivering aged care in that vast country. Part of these conversations related to how providers navigated the challenges of remote and rural care delivery.

In many ways the challenges faced by care providers in Scotland are not dissimilar – issues of workforce recruitment and retention, transport, cost of living, depopulation and lack of whole system thinking. I’ve previously written about what some of this means for the Highlands of Scotland and argued that at the very least we need to develop specific funding streams to address these issues, but in truth it is more than additional resource which is needed. The criticality of these issues is self-evident with growing numbers of care homes closing and public intervention required to avoid further social care withdrawal.

In this piece I want to suggest that there are some practical solutions which might aid us in the short term but also that if we are serious in addressing the challenges of depopulation then we need radical new (and old) approaches to our delivery of social care and health services. What follows is an attempt to describe some aspects of this in brief and to initiate a wider conversation.

Going back to move forward.

I have long been interested in the work of Eileen Younghusband. Eileen was a pioneering British social worker, educator, and researcher whose work significantly shaped social care practices, especially through her emphasis on community-based social work and a holistic, person-centred approach to care.

The Younghusband Report (1959) was a landmark document that analysed social services provision in the UK and made recommendations for integrating social work with health and community support. Her ideas laid a foundation for modern social care practices, particularly in settings where tailored, community-oriented approaches were essential.

In many senses she was the forerunner of our modern attempts at the integration of health and social care but critically her starting point was the local community and not national systems, and her focus was on the person living in community and primary care/social care and not on secondary and acute clinical care.

Younghusband’s work was grounded in the belief that social workers should operate within communities rather than distant institutions. She promoted integrated care models that involved close collaboration between social services, healthcare, and community organisations, enabling social workers to respond more effectively to local needs and provide tailored support. It all sounds remarkably prescient but sadly much of her report and recommendations remained on the shelf and unimplemented.

Her approach did however chime with many of those behind the development of the Social Work Scotland Act of 1968 not least in its emphasis upon a holistic approach to wellbeing rooted in universalist and communitarian principles.

Younghusband argued for a holistic model that viewed individuals within the context of their families, communities, and broader social environments. This approach encouraged social workers to address not just immediate social needs but also the underlying factors impacting an individual’s well-being, such as housing, employment, mental health, and social relationships.

Critically for our context today she also focussed on the importance of preventive measures in social care, including early intervention, education, and ongoing support to help individuals maintain independence and prevent crises. She also argued for the need for flexibility around the scope of roles and activities within professional groups, being critical of role protectionism and an unwillingness to work beyond scope and registration. I would suggest her work has much to teach us today around rural and remote health and care delivery.

Alongside this philosophical UK grounding of a communitarian primary and social care model it is worth reflecting on the Australian context which I came across.

Australia is actively working to improve access to and the quality of aged care services, particularly for those in rural and remote areas and from diverse cultural backgrounds. It is doing so by utilising several distinctive programmes including:

The Multi-Purpose Services (MPS) Program which has a primary aim to deliver integrated health and aged care services in rural and remote communities that cannot support standalone facilities. As a result, older people can remain in their communities, closer to family and friends, while accessing necessary care. The program encompasses a range of services including residential and home care, acute and subacute care, emergency, allied health, and primary health services. It is all funded jointly by the Australian Government and state and territory governments, with funding shared between them.

The National Aboriginal and Torres Strait Islander Flexible Aged Care Program aims to fund culturally appropriate aged care services for older Aboriginal and Torres Strait Islander peoples, primarily in rural and remote areas. It does so by recognising the importance of cultural safety in aged care, ensuring services respect and support unique cultural identities and needs. A key element of its success is that it emphasises worker registration and regulatory flexibility, cultural appropriateness, and accessibility, thus empowering communities to tailor services to their needs rather than expect people to fit into pre-existent structures and models.

Lastly the General Practice in Aged Care Incentive seeks to encourage continuous and quality primary care for older people residing in aged care homes by their regular GP and practice. Financial incentives are provided to GPs and practices registered with Incentive for providing regular visits and care planning. This has already resulted in improved continuity of care and a reduction in avoidable hospitalisations.

There are certain key themes in all these programmes including a stress on ensuring equitable access to quality aged care services for all Australians, regardless of location or cultural background. They seek to promote models that integrate various health and aged care services to provide holistic care and improve outcomes. And being very aware of issues of fiscal and demographic/geographic sustainability they directly address the challenges related to funding, workforce, and infrastructure to ensure the long-term viability of aged care services.

What does all this mean?

In rural and remote areas of Scotland, where communities are dispersed, resources are limited, and access to healthcare and social services can be challenging, Younghusband’s approach combined with some Australian insight offers, I would suggest, a potentially valuable framework for effective social care and health delivery. I would suggest four key aspects.

There needs to be a greater flexibility in the registration of services. The introduction of one registration requirement for any and all social care services would enable providers to exercise greater flex in the delivery of services. So, a residential care provider could also work in the community delivering care at home and day care/community supports. Whilst this is technically possible at the moment the process of dual registration and all that comes with it is cumbersome and stymies creativity and investment. Australia is rich in examples of the benefits of such a flexible approach to registration.

Clearly one of the major challenges is attracting and retaining a workforce. Again, Australia evidences what can be achieved when it is the person who is registered to work across multiple settings rather than limited in their scope and practice to one service or model of care and support. This serves to attract new workers because there is a clear appeal in working across environments, in the variety this offers a practitioner and in the positive ability of a worker supporting an individual across settings, transitioning from community through respite provision into permanent residential or advanced care.

Part of Younghusband’s work was her eagerness that such flexible approaches to professional role would become commonplace in integrated environments. We are not seeing this in Scotland, and I think this offers a direct challenge but also opportunity to nursing and social care colleagues. Many of us still remember the early models of district or community nursing which had a critical component of ‘social care’ and preventative approaches within them. Even if they were not always explicit, they existed in practice. These have largely been lost, but I would contend that in our rural and remote communities there is a real opportunity to re-envisage the role of community nursing in partnership with social care practitioners. Some lessons might be learnt from what is increasingly happening in our care homes in the relationship between senior carers and nursing staff. Faced with demographic challenges and a lack of available staff we need to be creative and positive about re-designing roles to fit population need rather than limiting the demand to fit traditional roles.

Thirdly, Australia also evidences a much more flexible approach to regulatory oversight and its role in service improvement and delivery. In Scotland today the role of the regulator is detached from service delivery and still dominated by a policing and compliance ethos rather than a collaborative, mutual partnership where critical comment and advice works alongside service delivery through service improvement. We are still at the stage of a naïve and sometimes limiting application of standards to practice rather than a consensual collaborative approach which enables services and supports to uniquely express local context and ability. To be blunt accepting that you cannot deliver a service in a remote community with limited staff in exactly the same way that might be possible in a populous urban setting does not mean that you lower standards, but it does require a much more dynamic, partnership oriented and realistic approach to regulation and oversight. Without such flexibility in oversight and regulation any innovation is stymied and limited.

Lastly and it is perhaps stating the obvious the reason Younghusband’s approaches did not see the light of day was that their cost was considered too great. The reason the approaches now being evidenced in Australia are clearly bringing benefit is that there has been a not insignificant amount of fiscal and resource investment. In other words, none of the above will be achievable without the money following the vision.

Scotland’s remote and rural communities are crying out for a spirit of innovative adventure where new models replace tired and outdated, defensive and protectionist approaches. A thriving and vibrant social care sector can be a major contributor to addressing the de-population of our communities – if we decide to make the effort and engage in the adventure.

Donald Macaskill

Photo by Konrad Hofmann on Unsplash

A week ago yesterday I was privileged to be delivering a session at the annual conference of the Australian Community and Care Providers Association in Adelaide. My theme was whether or not aged care and support could learn some lessons from the historical and traditional approaches to care of the dying and the support of the bereaved which occurred in north west Scotland and the Hebrides.

In describing what I argued to be some of the distinctive elements of the Hebridean approach I mentioned the practice of keening, and it has made me in the days since to have cause to reflect on just why it remains important today for those of us who work in the care and support of the dying and of the bereaved to give space and time to raw emotion and the real depths of grief. Let me expand on that a bit at the start of ‘To Absent Friends Week.’

‘Keening’ is perhaps one of the most distinctive Gaelic traditions around death and grief and was for centuries the norm in the islands of the northwest of Scotland and in parts of Ireland. Keening (caoineadh) was a form of ritualised mourning which involved wailing, crying, and singing to express grief. Historically, keening was performed primarily by women (often professional keeners) who would gather at funerals or wakes, helping the community express collective sorrow and marking the transition of the deceased. It involved a rhythmic and often emotional wailing or chanting, expressing sorrow for the dead.

This practice, while virtually almost gone in Scotland and a lot less common today in Ireland, was once central to the grieving process, helping both the mourners and the community release their emotions. In many ways it has similarities with traditional practices across the world. So, for instance Ghanaian Ga funerals involve elaborate, often loud ceremonies with song and dance that allow people to express sorrow publicly. In India in some regions, particularly in Rajasthan, women known as Rudaalis are hired to express grief openly, allowing families to engage with death publicly and vocally. And perhaps linked to Irish-Scoto heritage, in New Orleans, jazz funerals feature a blend of sorrow and joy, starting with a slow dirge and progressing to more upbeat music, allowing mourners to transition through grief and celebration.

Because of the stress upon helping the soul to journey onward which existed in the Celtic tradition, the Gaelic keening was not only an expression of grief but also seen as a way to guide the soul of the deceased to the afterlife. But centrally it helped the community come to terms with the loss, providing an outlet for collective sorrow.

The American writer Amanda Held Opelt argues that such raw expressions still have validity today. We all need sometimes in our grief the permission to fall apart, to lose decorum; to name the hurt deep inside and keening enabled Hebridean and Irish people to do that. It provided the ability to link yourself to the sadness of the past and of the moment and of the morrow.

Death is truly awful, and we need to create permission to fall apart. When we fail to allow space for the deep emotions of loss within the rituals of our grieving and at the heart of our bereavement then we store up hurt for days and years to come.  My own personal experience is that in our desire to distance ourselves from the painful reality and raw truthfulness of death, that as a society we have created an almost clinical detachment from grief and loss, not least around the immediate death, and that such has ill served our ability to express our deep emotions.

Expressing emotions like anger and lament in early grief (a process which the keeners facilitated so well) offers psychological benefits that can aid in the healing process. Studies highlight several key aspects of how such expression impacts grief recovery:

Allowing yourself to express anger helps individuals process complex feelings and begin to confront the reality of loss. This expression can also prevent emotions from becoming “bottled up,” which can lead to prolonged and complicated grief. By outwardly expressing emotions, individuals often find a path toward acceptance, which is crucial for moving forward (Verywell Mind, 2024).

Research from the American Psychological Association (APA) suggests that expressing grief-associated anger can alleviate physical symptoms linked to stress, such as increased heart rate and muscle tension. Suppressed grief can lead to long-term health issues, while allowing these feelings to surface can reduce stress hormones and promote physical well-being (APA, 2024). I don’t think it was accidental that the great thinker around bereavement Elizabeth Kubler-Ross argued that anger was a critical early stage response to loss.

Displaying emotions, including anger, allows others to understand the mourner’s needs better, fostering an environment where social support can be effectively provided. Such support is crucial for mourning, as studies indicate that those with strong support systems generally adapt to grief more healthily. This social validation helps mourners feel less isolated and more connected to others in their grief (Psychology Today, 2024).

Overall, openly expressing anger and sorrow can reduce the risks of complicated grief and enhance emotional regulation, which is critical for long-term mental health. This approach can encourage mourners to feel acknowledged and supported, offering a healthier path through bereavement.

Keening and other similar traditions from our historical approach to dealing with grief have, I believe,  much to teach us today and can offer powerful ways to honour grief, making mourning a communal rather than isolated experience, and allowing those left behind to feel supported and understood.

Fear not the tremble of hands

Grief, raw as iron struck red in the forge,

is not softened by silence, nor stilled by polite nods,

it erupts – fire in the heart’s quiet chamber –

burning with questions, cutting through fog.

For grief is more than sorrow, a deeper rage

at a world turned cold, that dare not yield

to the polite comforts, the softened sighs,

but roars at absence, demanding to feel.

Anger sharpens our sorrow, gives it weight,

a fierce testament to love’s deep scar,

a howl that shatters the pretence of calm,

declaring loss with a voice unbarred.

Let us not fear the tremble of hands,

the raw, unbidden tears that break

through our masks, these brittle walls,

for anger too is a holy ache.

It is a memory, an indignant vow

that love was real, that we will not erase

the fury of loss, the burn of despair,

nor will we hide what should be faced.

So mourn with untempered, furious grace,

let the heart unclench its tightly held song,

for in rage we honour what cannot be spoken—

and find, at last, where we belong.

Donald Macaskill

Photo by K. Mitch Hodge on Unsplash

This past week I have had the privilege of being a guest of the Australian Aged Care Providers Association. As well as being able to take part in speaking and workshops at their National Conference with over 2400 delegates attending, I’ve also been honoured to spend time visiting care and support facilities and projects in the area around Adelaide.

It’s been very insightful, and I want in a future blog to share some of what I discovered about how Australia is tackling issues facing aged care in remote and rural communities and whether there might be things we could adopt and adapt here in Scotland.

But without a doubt the most dominant topic of conversation during my seven days away has been what has recently occurred at the political level in Australia around health and social care.

In Scotland, the conversation around health and social care reform is urgent and vital, and there is no shortage of diverse opinions but it is often overshadowed by political squabbling as evident even in the last few days. Whether it is discussions about the National Care Service about which the Green Party will take a decision today or proposals to address workforce challenges including discrete approaches to immigration, these debates quickly devolve into party-political contests.

Along with many others I have stated before and am more than ever convinced having spent time in Australia that meaningful, sustainable reform of our health and social care system requires collaboration across the political spectrum. Such comment has been dismissed as utopian and folks have said to me it’ll never happen. But it can and I’m suggesting it should.

The recent experience in Australia – both with its Aged Care Act of 2023 and the ongoing 2024 reform, I believe, offers us an instructive example of how we can depoliticise health and social care reform and delivery and focus on the needs of people rather than the priorities of political parties.

The Australian Approach: A model for consensus

Australia’s aged care sector had long been in crisis, but it took the Royal Commission into Aged Care Quality and Safety to bring about comprehensive reform. The Commission’s recommendations resulted in the Aged Care Act 2023, which was a transformative piece of legislation. Central to its success was the bipartisan approach that Australian politicians adopted. After the release of the Royal Commission’s findings, the reforms were not treated as political capital for upcoming elections, but as a national imperative requiring cooperation.

In fact, the introduction of the new Aged Care Bill in 2024 was hailed as a rare instance of bipartisan commitment to long-term social care reform. Both the government and opposition worked together to craft a legislative framework that focused on the rights and dignity of older people. The Bill was designed to address systemic issues in funding, workforce support, and governance, with the shared understanding that reform was needed urgently. It is an ongoing process, and it is not quite over the line and the impressive Aged Care Minister addressed the conference and committed to robust partnership working with the care sector and those who use care supports. But there have already been massive strides including a huge eye-watering commitment to the workforce to increase terms and conditions, which has meant billions of additional resources committed to care and support.

In Scotland, we are at a similar crossroads. The need for reform is acute, but discussions around the National Care Service (NCS) have been mired in party politics and at present seem to be struggling and bogged down.

While every party and interest group including COSLA and the trade unions as well social care providers offers its version of how the care system should be funded and governed, the fundamental issues remain unresolved, and the people who rely on these services are left waiting. In the meantime, care workers continue to face burnout, residents in care homes lack the adequate resourcing of their care they deserve, and families remain uncertain about the future of social care provision in the community as homecare organisations struggle to continue.

Australia’s example shows us that progress is possible when political parties stop treating social care reform as an election battleground and instead commit to long-term solutions. There is a real need to bring all stakeholders – including politicians, care providers, workforce representatives, and, most importantly, the people who use these services – into the conversation.

Depoliticising reform: what can we learn?

1. Independent Commissions:

One of the reasons Australia’s reforms succeeded was the establishment of the Royal Commission, which provided independent, apolitical analysis of the problems facing the aged care sector.

Some might suggest that the Feeley Report was our Commission and indeed it garnered a lot of consensus when it was published. I don’t really think we need a Royal Commission as is being proposed in England – what we lack is political agreement on how you embed the proposals and vision of Feeley because I simply don’t think that is on the table at the moment. We have lost the collective vision at the hands of party political priority.

2. Bipartisanship:

Australia’s aged care reform was achieved through bipartisan negotiation. In Scotland, we must find ways to depoliticise care discussions by focusing on shared goals rather than divergent ideologies. Political parties in Holyrood must come together to agree on fundamental principles for health and social care reform. This may mean embracing ideas from across the political spectrum if they benefit the people who rely on these services and those who work in and deliver them. Those who work in and use care and support deserve real political leadership and a failure to come together and gain bi-partisan agreement will be a betrayal of the social care community and will not be soon forgotten. This is too important an issue to be kicked into the long grass, ignored or indeed fought over in a Holyrood playground.

3. Stakeholder-Led Design:

The success of Australia’s Aged Care Act also rested on the involvement of a wide range of stakeholders. In Scotland, it is essential that any future reform is designed with the input of the people most affected – those receiving care, their families, and the workforce and employers. We have palpably failed to achieve this thus far because despite the warm rhetoric of embedding design approaches stakeholder engagement has been partial and non-inclusive. We cannot afford to continue to have reform designed by civil servants and politicians.

The inclusive Australian approach has ensured that the reforms are not only effective but also respected by those on the frontlines of care delivery.

4. Long-Term Vision:

One of the issues plaguing Scottish social care reform is the tendency for short-term fixes based on political cycles. Australia’s reforms, while still unfolding, have aimed for a long-term vision of sustainability. By creating a framework that stretches beyond electoral timelines, Australia has demonstrated that meaningful change takes time but is worth the investment. The fruit is already evident even within months of change  – workforce retention has improved, and recruitment has become easier because people can see that they are respected and valued maybe for the first time as a key economic sector in Australia. Scotland’s care system, like Australia’s, must be built for the long haul, with consistent funding, workforce support, and regulation designed to last for decades, not just until the next election.

Rebuilding Trust in the System

Australia’s reform process has also been about rebuilding trust in the system. The Aged Care Act of 2023 included provisions for better oversight, accountability, and transparency – elements that were critical in restoring public confidence. Scotland faces a similar challenge. Years of underfunding, mixed messages, and inconsistent policies have eroded trust in social care provision. We need clear, transparent policies that offer stability to those who rely on these services, those who work in them and those who provide them.

In conclusion, as we look to the future of health and social care in Scotland, we must be willing to take party politics out of the equation. Reforming our social care system to say nothing of the NHS, is not about winning elections; it is about ensuring that every person, whether receiving care and support or providing it, is treated with the dignity, respect, and support they deserve. Australia’s experience shows us that bipartisan, human-centred reform is not just possible – it is necessary. Scotland must follow suit and commit to depoliticised, evidence-based solutions that put people at the heart of our care system.

What do our politicians say? Are they brave enough to let go the levers of power, both local and national, and to allow a wider conversation and control? Or will we continue to squabble, disagree and dissent?

Donald Macaskill

Photo by Kay on Unsplash

Today is the last day of International Infection Prevention and Control Week. It’s a week which has been centred on its theme which this year is “Moving the Needle on Infection Prevention.” including a focus yesterday (Friday) on the care continuum and long term care settings.

I have thought about infection prevention and control a great deal in the last few years not least because of my conviction that as a health and care community we got it so badly wrong during the Covid pandemic. In workshop and conference sessions and in evidence submissions I have argued that we need to adopt a much more human rights-based approach in the face of any future pandemic or major event.

The following blog is an attempt to start a conversation on what I mean by a more human rights based approach to IPC, because I honestly do not think that the current Antimicrobial Resistance & Healthcare Associated Infection (ARHAI) Scotland guidance for social care settings is acceptable or human rights based and because I am fearful that another future event will again be dominated by a public health approach devoid of a robust human rights focus.

At the very least the tone and language of associated documentation and practice – including the material produced for the IPC Week – has to start to reflect the reality that a care home is someone’s home and its residents are autonomous individuals with human rights and not occupiers of a space and place of clinical practice. I would go even further and suggest that much of existing IPC guidance for hospital settings is devoid of a human rights perspective.

The Covid-19 pandemic has forced us to re-examine many aspects of our society, and nowhere has this introspection been more needed than in the care of older persons both in our community and in our residential care settings. Care homes became, during the pandemic, epicentres of vulnerability. Lives were lost, families were shattered, and the reverberations continue to be felt. Yet, there is now an opportunity for radical transformation – a move towards a human rights-based approach to infection prevention and control (IPC). This approach prioritises the dignity, autonomy, and the well-being of individuals while ensuring safety and care standards that protect the most vulnerable.

It is impossible to discuss the need for change without reflecting on the trauma that Covid-19 brought to care homes. The pandemic introduced extraordinary measures in care homes: strict lockdowns, isolation, and visitation bans, all in the name of infection control. While these interventions were aimed at protecting physical health, they often resulted in deep social, emotional, and psychological harm to residents, families and staff.

Research has shown that, particularly in the early phases, decisions were made rapidly, and often with a singular focus on controlling infection at the expense of residents’ broader human rights. Lockdowns, blanket visiting bans, and restrictive practices – while intended to protect – often resulted in loneliness, isolation, and psychological distress for residents. A Lancet study noted significant increases in depression, anxiety, and a decline in cognitive health during prolonged isolation in care homes (Hanna et al., 2021).

For many, particularly those living with dementia, the loss of daily contact with loved ones, the curtailment of social activities, and even changes in routine caused irreversible deterioration. Studies like those by the Journal of the American Medical Directors Association (2022) indicate a notable decline in cognitive function and mental well-being in residents subjected to prolonged isolation.

This experience starkly highlighted that safety cannot be achieved at the expense of dignity. The desire to prevent infection must be balanced with respect for autonomy and a person’s right to live a life that is meaningful, connected, and dignified.

Post-Covid, we are faced with an urgent question: How can we protect residents from future infectious threats without compromising their fundamental human rights?

A Human Rights-Based Approach: The Framework

A human rights-based approach (HRBA) to infection prevention and control focuses not only on the technical aspects of controlling infection but also on the values and principles of human dignity, autonomy and personal choice and control. Such an approach involves placing the individual, their dignity, and their autonomy at the centre of care. This is not a simple balancing act but rather a framework that embeds human rights principles into every aspect of decision-making, care delivery, and policy formulation. The technical and clinical dominance of IPC measures however valid should never be at the expense of individual human rights.

1. Participation and Autonomy

One of the cornerstones of a human rights-based approach is respecting the autonomy of the individual. Throughout the pandemic, many older people in care homes had little or no say in decisions about their lives, often because those decisions were made quickly and with public health as the primary focus. Moving forward, we need to ensure that residents, their families, and care staff are active participants in decisions about infection prevention and control. This includes not only informing residents about risks but also allowing them to make choices that reflect their values and preferences. A person’s right to family life, for example, should not be easily overridden in the name of IPC.

2. Proportionality

The principle of proportionality requires that any measures taken are the least restrictive necessary to achieve the intended goal. In the post-Covid era, IPC measures must be carefully calibrated to avoid overreach. Blanket bans on visits or social interaction cannot be justified when more nuanced and individualised approaches, such as testing or social distancing, can be employed. Research has underscored the importance of maintaining human contact for well-being, and we must ensure that future measures respect this vital need. The speedy implementation of the full scope of Anne’s Law in Scotland is a case in point.

3. Dignity and Quality of Life

Infection prevention measures should never undermine the dignity of the residents. For many in care homes, quality of life is just as important – if not more so – than mere survival. Research from The British Medical Journal (2023) highlights the severe psychological impact of extreme restrictions, noting that many residents felt “dehumanized” by the rules that governed their daily lives during the pandemic. Any IPC framework must therefore prioritise preserving a sense of normalcy, allowing individuals to continue engaging in activities that bring them joy, purpose, and connection.

4. Accountability and transparency

During the pandemic, decisions were often made behind closed doors, with little transparency or input from those most affected. A human rights-based approach requires a commitment to openness and accountability. Care home residents and their families must have access to clear, honest information about the reasons behind any IPC measures and be provided with opportunities to voice concerns, ask questions, and seek redress if they believe their rights are being infringed upon.

Learning from research Post-Covid

In the aftermath of the pandemic, research has provided us with critical insights into how IPC measures can be designed to protect both physical health and human rights. For instance, studies suggest that hybrid approaches to visiting can significantly reduce infection risk while maintaining essential social connections. Additionally, a study published in Age and Ageing (2022) highlights the effectiveness of integrating regular testing and infection control education for both staff, residents and family which can reduce the need for more draconian restrictions.

Crucially, research has also shown that infection control policies developed in partnership with residents, staff, and families not only yield better outcomes but also foster greater trust and compliance. Involving people in these processes reinforces the sense that they are not passive recipients of care but active participants with rights that are respected and upheld.

A path to ethical IPC care

The lessons of Covid-19 demand that we rethink our approach to infection prevention in care homes. It is no longer acceptable to prioritise safety in a way that strips individuals of their humanity. A human rights-based approach offers a framework through which we can safeguard residents’ health while also affirming their dignity, autonomy, and right to a meaningful life.

As we look to the future, we must commit ourselves to an ethic of care and support that is not only responsive to the needs of infection control but also rooted in the rights and dignity of every older person. This is not just a policy shift; it is a moral imperative.

We owe it to our older generation to create a future where care and support in a care home during a pandemic is not about survival alone but about living fully, with personal and individual choice, even in times of crisis. We really do need to ‘move the needle’ and reset the human rights conversation on IPC.

Donald Macaskill

Photo by Kelly Sikkema on Unsplash

I’ve mentioned quite a few times over the years about how restorative and important nature is for me, whether that be the countryside or hills, or more recently having the privilege of living by the sea. Sometimes simply walking renews but at other times listening to a podcast adds to the experience.

Earlier this week I listened to what is becoming one of my favourite podcasts. I must confess that I was a late arrival to the world of podcasts but now I appreciate the sheer ease and benefit of getting entertainment, inspiration and knowledge through such an accessible media, whether I am relaxing, travelling or avoiding! One of my favourites has become the BBC’s science podcast ‘Instant Genius.’

My latest one was focussed on the work of Prof Kathy Willis who is the Professor of Biodiversity in the Department of Biology and Pro-Vice-Chancellor at the University of Oxford. I found it inspiring! She was talking about her new book which was published a few weeks ago, entitled ‘Good Nature: The New Science of How Nature Improves Our Health.’ In it she explores the powerful connection between nature and human well-being, drawing on scientific evidence to argue that our interaction with nature has profoundly positive effects on our physical and mental health.

It is a fascinating book full of insights and it started me off thinking about experiences in care homes and in communities. Put simply I think there is very real physiological and neurological benefit in us all becoming more aware of the role that the natural world plays in enhancing our health and wellbeing and I consider that such insights have a lot to teach us about how we have to develop the care and support of older people in the years to come.

I’ll use Kathy Willis’ work to illustrate some of this not least because her work is grounded in robust scientific evidence that demonstrates the impact of nature on human health. I think there are four areas which her work demonstrates which are applicable to care home and homecare provision.

The first is improving mental health. Willis highlights the growing body of research that shows how exposure to nature can reduce stress, anxiety, and depression. She notes work from the University of Exeter Medical School where researchers have shown that living near green spaces or spending time in nature is associated with lower levels of depression, anxiety, and stress. Their study highlights the mental health benefits of access to natural environments in urban settings. She also refers to a study published in The Lancet Planetary Health. This large-scale study, which linked exposure to green spaces with reduced mental health medication use, showed a tangible connection between nature access and improved mental well-being.

I suspect many of us have known the instinctive truth that spending time in green spaces, such as parks and forests, has health benefits but it is really positive to have respected international research to show evidence of lowered cortisol levels (a marker of stress), improved mood, and enhanced cognitive function. In her book Willis delves into the mechanisms behind this, such as how natural environments can restore attention, promote relaxation, and provide a break from the overstimulation of urban life.

For care home providers, this suggests the importance of integrating nature into the daily lives of residents. This could ideally be achieved by creating outdoor spaces with accessible gardens, utilising colour and sensory differentiation for those living with dementia and planted beds at a height which would enable people to continue gardening. Many care homes already have such spaces but if outdoor space isn’t possible then even small indoor areas with plants and trees can offer a calming environment that promotes relaxation and reduces anxiety. Those living in their own homes can be encouraged (or supported) to spend time in nearby parks or outdoor areas and they will evidentially achieve similar benefits from the therapeutic effects of fresh air and greenery.

A related theme in Willis’s work is the physical health benefits of nature. One of the book’s key arguments is that regular exposure to nature can improve physical health. This includes lowering blood pressure, reducing the risk of cardiovascular disease, improving immune function, and promoting physical activity. She shares the insights of ‘Forest Bathing’ (Shinrin-yoku) in describing the research of Dr Qing Li  from Japan, which demonstrates how spending time in forests can lower stress levels, reduce cortisol concentrations, and boost immune function by increasing natural killer cells in the body. This work highlights the physiological and psychological benefits of immersion in natural environments.  She also references studies on phytoncides, organic compounds released by trees, which have been shown to lower blood pressure and improve overall cardiovascular health when inhaled during time spent in forests.

A further study from the University of East Anglia reviewed data from over 140 studies involving more than 290 million people and found that spending time in green spaces was associated with reduced risk of cardiovascular disease, lower heart rates, and lower rates of premature death.

Willis emphasises that access to nature encourages people to be more active, whether through walking, hiking, or other outdoor activities, which directly benefits physical health. Her research and that of others would suggest that for care home residents, particularly those with limited mobility, even moderate interaction with nature can have significant health benefits.

But it is perhaps when we move into a cognitive and neurological realm that nature comes into its own according to Willis. Many of the studies she quotes relate to children, but I would suggest there is a potential benefit in similar research for older adults. For children she cites work from the Barcelona Institute for Global Health which shows that children who have regular exposure to green spaces perform better on cognitive tests, have better attention spans, and show fewer signs of attention deficit hyperactivity disorder (ADHD). This research supports the idea that natural environments enhance children’s cognitive development and mental well-being.

In addition, studies from the US and Scandinavia show outdoor play in natural settings, like school gardens or green play areas, helps foster creativity, problem-solving skills, and social cohesion among children. Why would there not be similar cognitive benefit for older adults?

Indeed, Willis suggests that exposure to nature, particularly for older adults can help improve attention, memory, and cognitive function, making it a valuable resource for those living with dementia or other cognitive impairments. As many practitioners in care home and community care know this can be achieved through cognitive memory activities or using the natural world to manage agitation and confusion. Providing access to outdoor areas, with calming elements like water features or gentle landscaping, can and does reduce anxiety and restlessness.

Fourthly, as a leading advocate of bio-diversity Willis has a lot to say on this subject as it relates to immunology, which is one of our major challenges in residential care and support environments as well as care and support for older persons in the community. She explores the “biodiversity hypothesis,” which suggests that exposure to biodiverse environments can improve immune system functioning. She cites research from the University of Helsinki’s Immunological Department indicating that people who spend time in biodiverse green spaces have stronger immune responses, in all likelihood because they are exposed to a wider range of microbes, which helps “train” the immune system to be more adaptive and less prone to inflammatory diseases like allergies and asthma. She quotes research from Finland that showed children who attended daycare facilities with biodiverse outdoor play areas had significantly higher immune system activity and fewer incidences of inflammatory conditions compared to those in urban, less biodiverse settings.

Willis’s work has many insights but also contains no little challenge especially for urban designers and architects. Her challenge is as valid for care home and residential support developers as any others. In her study she addresses the issue of unequal access to nature, noting that disadvantaged communities often have less access to green spaces, which can exacerbate health inequalities. She advocates for better urban planning and policy changes to ensure that everyone, regardless of socioeconomic background, can benefit from nature’s health-boosting effects.

I found Willis’s work stimulating and thought-provoking – in many senses it portrays nature and the natural world as a prescription for wellbeing. Indeed, she explores the concept of “nature prescriptions”, where she cites some of the work of NHS Scotland which has explored the potential of nature-based interventions to reduce healthcare costs, with preliminary findings showing that patients who engage in nature-based activities, such as walking in parks, have better health outcomes, reducing their reliance on medication for conditions like depression, anxiety, and cardiovascular disease. Willis presents this as a growing trend backed by scientific evidence and discusses how it could become an integral part of preventive health and social care.

In Good Nature, Kathy Willis makes a compelling case for the vital role that nature plays in enhancing both mental and physical health. She calls for more research, better access to nature, and policy changes that recognise nature as a fundamental element of human well-being. Her work argues that reconnecting with nature is not just a luxury but an essential part of a healthy life, advocating for integrating green spaces into everyday environments to benefit all.

The challenge for care home and homecare providers is self-evident – how do we grasp it and make the natural world an ally in our care and support? How do we put nature into the heart of our care planning and support, our service offer and pattern of care? How do we maximise the potential of nature as therapy, incorporating elements of “green therapy” or “horticultural therapy” into care programmes to enhance both physical and emotional well-being, allowing residents or home care clients to benefit from hands-on engagement with nature?

Nature should not be seen as an optional or secondary consideration but as an essential part of promoting well-being. Whether through creating accessible green spaces, encouraging outdoor activities, or using nature-based therapies, care providers have the opportunity to transform the care and support experience by reconnecting residents, those who live in our communities and the care and support workforce with the natural world.

Donald Macaskill

Photo by v2osk on Unsplash

 

It’s been an interesting week where the answer to that question might be both a yes and also a no. Indeed, in the opinion of the Sacha Deshmukh, the chief executive of Amnesty International UK, Scotland has moved into the ‘slow lane’ in terms of human rights advocacy and advancement.

Quoted in The National ahead of a meeting with First Minister John Swinney on Tuesday, Deshmukh said that:

“I’ve got a big concern that Scotland is in danger of moving from the fast lane to the slow lane on human rights…

“I’m not sure whether that is an intentional choice or it’s the result of a series of different choices. But it’s definitely a concern at the moment and obviously one that I think would be really bad.”

He was commenting following the decision of the current administration not to bring forward a Human Rights Bill in the current term of the Scottish Parliament. It was wholly absent from the Programme for Government.

I’ve written on a number of occasions about how that Bill and the proposals to incorporate into Scottish law various conventions especially the International Covenant on Economic, Social and Cultural Rights (ICESCR) gave those concerned about social care and older persons’ human rights a very real opportunity of moving forward both legally and practically. But it would appear that the current administration has found such a Bill to be a distraction or at best not to be a priority.

The Scottish Government has challenged this critique arguing that it wants to continue work on the Bill including more consultation and to ensure that any proposals especially those that might affect reserved matters are properly worked through with the new UK Government. All very reasonable but personally I don’t think such work means you cannot at the same time bring a Bill forward – that is not if you thought it important!

In a week when we’ve celebrated the UN International Day of Older Persons, it’s made me reflect on just how much we have or have not protected the human rights of older persons in Scotland

So, on the positive side of the scales let me start by acknowledging the positive steps we’ve made. In recent years, Scotland has taken a more rights-based approach in health and social care. We have legislation that enshrines the rights of older people to dignity, respect, and autonomy. We’ve seen campaigns, initiatives, and policies aimed at combating ageism. And yet, despite these advances, the lived experience of many older people in Scotland does not reflect these rights in action. That is the uncomfortable truth.

At a glance, one might argue that human rights are universal, and that older people are covered by the same frameworks that protect all citizens. However, dig a little deeper and it becomes abundantly clear that, despite fine rhetoric and grand declarations, older people are systematically overlooked, neglected, and their rights subtly diminished by the institutions that claim to safeguard them.

First, let us consider the fundamental right to health and social care. This is not just about access to services but about ensuring the best possible quality of life for older people. Are we truly upholding that right?

Too often, I hear stories of older Scots facing unacceptable if not obscene delays in accessing the care they need or worse still having services taken away from them. Services are stretched thin, and while the dedication of social care professionals is unquestionable, the systems that support them fall short. We must ask ourselves: Is an older person left to wait months for essential care truly having their right to health and social care upheld? Are we just waiting till they die and stop being a statistic? Is someone forced to choose between heating their home and paying for food experiencing dignity especially now the UK Government has decided that a universal benefit should be withdrawn?

Far too often, the fundamental rights of older adults are compromised or ignored under the guise of resource constraints, logistical challenges, or worse, societal attitudes that reduce older people to burdens. This narrative is corrosive and dehumanising.

The pandemic laid bare many of these issues. It revealed the vulnerability of older people, particularly those in care homes, where a lack of resources, inadequate protection, and isolation threatened not just their physical health but their mental and emotional wellbeing. Human rights should never be something that we remember only in times of crisis; they should be embedded in everything we do—every policy, every decision, and every action. It is clear that that’s no longer a priority for some in our political leadership.

Another cornerstone of human rights is the right to autonomy—the right to make decisions about one’s own life. For older people, this is often eroded, sometimes unintentionally, sometimes systematically.

Take for example the decisions around care and where someone lives. All too often, older people are not given adequate say in whether they can remain in their own home or whether they must move into residential care. Increasingly money talks louder than rights. We must ensure that our citizen voices are central to these decisions. Because when autonomy is removed, we strip away a person’s sense of self, their dignity, and, ultimately, their humanity.

I want to stress that older people are not just passive recipients of care or services; they are individuals with skills, experiences, and contributions that enrich our society. Age should never be a reason to sideline someone’s opinions or contributions. We need to do better at ensuring older Scots are active participants in the decisions that affect their lives, their communities, and the nation. We are currently doing to rather than working with older Scots.

Underpinning so many of these challenges is ageism—the silent, often unspoken discrimination against older people that exists in our society. Ageism permeates our culture, from the language we use to the policies we create. And let us be clear: ageism is a human rights issue. It denies older people the respect, care, and inclusion they are entitled to as equal members of our society.

The way we treat our older population is a reflection of who we are as a society. Do we see them as burdens, or do we value them for the richness of their experiences, their wisdom, and their enduring contributions?

So, where do we go from here? We cannot afford complacency. Human rights are not a static concept; they require vigilance, effort, and commitment. Part of that means we need political leadership that seeks to advance rather than park human rights. Are we doing enough to create a society where every older person can live with dignity, respect, and choice?

Our government must continue to embed human rights frameworks into the heart of social care policy. Funding must be prioritised for the services that older people rely on. We need to reimagine care, towards person-led approaches that place autonomy at the core. But above all, we need to challenge ageism in every corner of our society.

The question, “Are we upholding the human rights of older Scots?” may not have a simple answer, but one thing is clear: we must do better.

In the words of the poet…

In quiet rooms…

In quiet rooms, where time holds sway,

Where voices soft might fade away,

Do we, as a nation, pause to see

The elders’ right to dignity?

 

For years they’ve walked our country’s land,

Built homes with care, with steady hand,

And now, in age, they seek to find

The rights that every heart’s entwined.

 

The right to live, to breathe, to be,

Not silenced by our apathy,

To make their choices, bold and clear,

To live with love and without fear.

 

Yet still we falter, still we fail,

As systems creak, as hopes grow pale,

Isolated in their prime,

Forgotten in the march of time.

 

But human worth does not expire

With age, nor dim with life’s spent fire;

Their wisdom grows, their spirit gleams,

Their rights are more than fragile dreams.

 

It is our task, our cause, our fight,

To lift their voices into light,

To banish ageism’s cruel sting,

And let their song of justice ring.

 

For our strength is measured here,

In how we treat those we hold dear.

The old, the frail, the wise, the bold—

Their rights are ours, their stories told.

 

So let us stand, hand clasped in hand,

And honour them across the land,

For in their rights, our future lies,

In every tear, in every rise.

 

Let justice flow like our streams,

A nation built on human dreams,

Where old and young together strive

For human rights that breathe, that thrive.

 

Donald Macaskill

I have had the honour over a couple of days to be attending and speaking at the European Ageing Conference and during that time to further my own knowledge about and awareness of the delivery of care and support to older people right across Europe I have been talking to lots of practitioners from many countries.

Inevitably such conversations lead you to share and talk about what is happening in your own country. These reflections have also come about at a time when I have been considering what it is was or maybe should be distinctive about the way social care is delivered in Scotland, not least because a few have challenged me as to whether our claims to be ‘different’ in Scotland stand up to any serious scrutiny!

My starting contention is that both in policy articulation, legislative underpinning and in practical application that our approach in Scotland is distinctive, and not just within the United Kingdom but across Europe.

There are for me four main strands which come into play here, firstly policy grounded in a commitment to human rights, a legislative focus upon person-centred or person-led care and support, a particular emphasis upon the nature of community and what is meant by the ‘social’ in social care’, and lastly the belief that social care should be a fundamental right accessible to all who need it, what might be termed a universalist position. These are all somewhat interrelated.

It might be helpful to start with what I would suggest is the foundation of social care universalism.

At the heart of Scotland’s social care philosophy is the principle of ‘universalism.’ We see this particularly relevant within the foundational Social Work Scotland Act of 1968. Scotland has chosen to take a path where social care and support is seen as a public good – a service that should be available to everyone, based on need and not on the ability to pay. This approach contrasts sharply with many parts of the UK and Europe, where social care can often be a postcode lottery, heavily means-tested, and dependent on local funding and resources.

For instance, Scotland’s decision to provide ‘free personal care for those over the age of 65’, regardless of their income or savings, is a testament to this universalist ethos. This policy, in place since 2002, and extended to people under 65 in 2019, has ensured that older people in Scotland receive essential support, from help with bathing and dressing to preparing meals, without the fear of unaffordable costs.

I would be the first to accept that such a universalist policy does not come without consequence not least in terms of sucking up limited resource at the expense of preventative and more upstream interventions. Universalist approaches cost resource and cannot be achieved on the cheap and without fiscal prioritisation.

Nevertheless, as has been seen in the reaction to the UK Labour Government’s recent decision to end the universal principles behind the Winter Fuel Payment, the defence of universalism as a mechanism for social care and advancing wellbeing and addressing health inequalities is robust in Scotland, whether that be prescriptions, bus travel or carers allowance and child support like the Baby Box.

Universalism is a distinctive approach to social care provision not at the moment commonly seen to the same extent elsewhere in Europe. Indeed, many in Scotland would like to see its extension not least to reduce the inequality of treatment and care response to conditions such as dementia.

The universalist approach is not accidental, but I would suggest rooted in a particular emphasis upon the ‘social’ – of which more later. But for now, it is worth stating that the idea of the social relates to broader questions of ‘justice and equality.’ Social care, when viewed through a social lens, is about ensuring that all individuals, regardless of their personal or economic circumstances, have the opportunity to live with dignity. Philosophers like John Rawls emphasise that societies must ensure a fair distribution of resources, including care, so that individuals are not disadvantaged by circumstances beyond their control. The social component of social care thus implies that care is a ‘public good’ and a ‘collective responsibility,’ that there has to be a ‘universalist’ emphasis, that it is not just a private or familial duty as was often the case in earlier care and support in Scotland as elsewhere.

The second dominant strand I’ve mentioned that is distinctive though not perhaps so unique in Scotland is a commitment to human rights and person-centred or person-led care and support.

At least in legislation and policy if not sadly fully in implementation Scotland has embraced a model where care and support is not simply about managing needs or balancing budgets but about recognising and valuing the inherent dignity and worth of every individual.

The Social Care (Self-directed Support) (Scotland) Act 2013 embodies this philosophy at its best. It gives individuals greater choice and control over their care, enabling them to decide how their support is provided, whether through direct payments, direct public sector care services, or those purchased from independent providers or a mix of all. This is about putting the person at the heart of their own care journey, empowering them to shape the support they receive around their own needs, aspirations, and preferences. It should not be about maintenance but about enabling a person to thrive and flourish.

It strikes me in some of the conversations I have held that elsewhere in Europe, social care can still be overly bureaucratic, prescriptive, and service-led, Scotland has taken steps to ensure that individuals are not passive recipients of care but active participants in their own lives. This is a fundamental shift, from a paternalistic model of care to one where the rights, choices, and voices of those who use care and support services are prioritised above all else.

This is a journey, and we have a considerable distance to go to its full realisation in Scotland and for me I believe that this has to be grounded by embedding the human right to social care as part and parcel of the development of wider human rights legal protections.  Added to this is the urgent requirement to develop mechanisms to ensure adequate redress where bodies and persons are found not to have acted in a manner which upholds the human right to social care.

A third and further strand which I think is distinctive is an emphasis on the ‘social’ and the communitarian and a resultant focus in policy if not sufficiently in practice upon prevention, early intervention, and community-based care and support. There is an accepted understanding that the best way to support individuals is to prevent the need for more intensive care in the first place. This means investing in community services, promoting health and well-being, and supporting people to live independently for as long as possible.

This, for me at least, stems from a dominant philosophical and policy thread in Scotland which emphasises the ‘social’ in ‘social care’ and indeed ‘social work’ – it’s one of the reasons why the increasing use of the phrase ‘health and care’ rather than ‘health and social care’ is for me more than just a linguistic irritation.

The concept of the ‘social’ in social care carries significant philosophical and policy implications. It reflects both an ethical understanding of human relationships and obligations and shapes the ways in which care is structured and provided within societies.

Philosophically, the concept of the ‘social’ emphasises the ‘interconnectedness of individuals within a society.’ It moves beyond a purely individualistic view of human needs to recognise that care, well-being, and health are deeply rooted in social relationships and structures. It reflects ideas in ‘communitarianism’, which argues that individuals are embedded in a network of social relationships and that their well-being depends on their connections to the community. It also challenges the more atomistic views of human beings that are often emphasised in liberal or market-driven frameworks, which tend to see individuals as self-sufficient.

Such a social and communitarian understanding is, I would contend, rooted in the pages of the 1968 Social Work Scotland Act – services are there not to be an end in themselves but to enable people to be as independent as possible. The 1968 Act is foundational in that it established local authorities’ responsibilities for providing social work and social care services in Scotland. It outlines the duties of local authorities to assess needs and provide appropriate social care services. The Act remains a cornerstone of social care legislation in Scotland, forming the basis for subsequent reforms and additions.

Its emphasis upon independent living was strikingly different from what had come before with a stress upon institutional care and support. But independent living was not about living alone, separate or detached from others. Social care is deeply communitarian in that it was and is about enabling people to be part of their communities and to actively – should they desire – be able to exercise the full citizenship of belonging to the local community. This is about an approach to care and support where the resourcing and developing of community supports and connections is as profound a dimension of social care as the delivery of direct services.

This approach also represented a more holistic understanding of social care, seeing it not just as financial support but as comprehensive care that also included social and emotional support within the community context.

Critically and perhaps something that in straitened financial times is forgotten was that in the 1968 Act local authorities were also empowered to intervene and offer social services aimed at ‘promoting well-being’ and addressing a wide range of social issues, including poverty, family problems, and issues faced by children and the elderly.

Therefore to sum up – a critical aspect of the distinctiveness on social care in Scotland is the emphasis in policy and philosophy upon the ‘social’ within social care. Its importance is because philosophically it highlights the relational, collective, and ethical dimensions of care, positioning it as a core aspect of human interdependence and moral responsibility. In policy terms, it shifts care from being a private, individual matter to one of public responsibility, leading to state involvement, universal access, and the integration of care within broader welfare systems.

In conclusion, I think there are reasons to be proud of and celebrate Scotland’s distinctive approach to social care, but at the same time we know there is still much more to be done. The proposed National Care Service (NCS) represents a historic opportunity to take forward the values of universalism, human rights, and person-led ‘social’ care and support on a national scale. But it is also a moment that calls for courage, vision, and a steadfast commitment to the principles that have made our approach to social care unique. I will leave for another time a reflection as to whether or not the current NCS proposals achieve that protection and further realise the vision.

In Scotland, we are on a journey — one that embraces a distinctive path marked by fairness, equality, and the belief that everyone has the right to live a full, independent life. There are obvious risks to a universalist approach that emphasises the social within care and support and that embeds dignity and human rights. Ignoring them with naive dreaming will not protect what has been developed over the years.

Social care in Scotland should not be seen as just a service or model – it is a testament to the kind of society we are and the kind we aspire to be, and that’s a social one!

 

Donald Macaskill

Photo by Shane Rounce on Unsplash

Today, is World Alzheimer’s Day, and every year when this day comes around I’m sure I am not the only one who pauses to remember the lives I have known, not least my own late mother, who have been affected by dementia. It is a day for reflection and remembrance but also, I think a day when we should seek to re-focus and renew our efforts and energies in the battle against this pernicious disease.

I have spent a couple of days in London this past week at various meetings and been inspired by people and projects which are every day seeking to make a difference to those who are living with dementia and to their families and friends. And the emphasis upon ‘living with’ is important.

It’s also been a time when I’ve been reflecting on the extent to which things have changed for better or worse in our support around dementia in Scotland.

Scotland has long been recognised as a leader in progressive dementia care. Our approach is shaped by a commitment to compassion, human rights, and person-led support. I really do sincerely believe and have personally witnessed the truth that this commitment is not just a policy or a strategy; not just rhetoric and empty words but it is a deeply held conviction that every person living with dementia should have the right to live their lives to the fullest, regardless of their diagnosis.

The Scottish Government’s Dementia Strategy, now in its third iteration, ‘Everyone’s Story’, continues to focus on key priorities: ensuring timely diagnosis, providing personalised care and support, and promoting the rights and participation of people living with dementia. It recognises that dementia is not just a medical condition but a profoundly human experience that affects every aspect of life. That is why our approach in Scotland is aimed at being holistic — it encompasses healthcare, social care, community support, and a commitment to upholding the human rights of those living with dementia and their families.

I have been vocal in my contention and criticism that all these positives without an underpinning of resource and fiscal prioritisation are leaving the dementia community in Scotland far short of the aspirations and goals we all want to achieve. We will sadly never ensure that every person living with dementia is supported to live well and with dignity unless we are prepared to pay for that fulfilment to become reality. Indeed, the experience of so many living with dementia at the moment is care packages cut and waiting weeks to get a care home placement – all suggesting a lack of fiscal priority.

Social care practitioners in Scotland recognise that people with dementia are not passive recipients of care but active participants in their own lives. Our task is to support their autonomy, enable choice, and promote independence.

One of the most important developments in recent years has been the adoption of a human rights-based approach to dementia care, grounded in the principles set out in the UN Convention on the Rights of Persons with Disabilities (UNCRPD). This approach ensures that people living with dementia are treated with dignity and respect, that their voices are heard, and that they have access to the support and services they need to live well in their communities.

But perhaps the one thing which I celebrate the most today is the way in which the isolating nature of dementia is being addressed up and down Scotland through the work of dementia friendly communities and meeting centres. These communities are not just about putting up signs or making superficial changes; they are about fostering real understanding, compassion, and connection.

A dementia-friendly community is one where every individual, from shopkeepers to bus drivers, from teachers to local government officials, understands the condition and knows how to respond with empathy and practical support. It is a community where people with dementia can continue to do the things they love — go to the football match, visit the library, or simply enjoy a cup of tea with friends.

It is no accident that Scotland’s approach to dementia is rooted in community, for such is the heart of all social care. Dementia affects not just the individual but their family, friends, and the wider community. It is critical to recognise the community dimension of dementia and other long term conditions and to affirm that communities have a vital role in supporting people with dementia and creating environments where they feel safe, valued, and included.

But we must also recognise that true community inclusion goes beyond creating welcoming spaces; it is about ensuring that people with dementia have meaningful opportunities to participate in community life. Whether it’s through volunteering, participating in social activities, or simply having a chat with a neighbour, every connection matters.

Equally on this day we cannot forget the thousands of unpaid carers — the family members, friends, and neighbours — who provide the bulk of care and support for those living with dementia. They are the true frontline of care and compassion, often juggling work, family commitments, and their own health, while providing loving, tireless care.

In Scotland, we are committed to supporting these carers, who are often stretched to their limits physically, emotionally, and financially. The Carers (Scotland) Act 2016 has been an important step forward, offering carers a right to support, advice, and respite. However, there is still a huge amount still to be done to ensure that carers are recognised, valued, and supported in their own right.

On this World Alzheimer’s Day, we must renew our commitment to supporting these carers. The Carers Act was a significant step forward, but we must do more. We need to ensure that every carer has access to the support, respite, and recognition they need and deserve. No carer should ever feel alone, overwhelmed, or undervalued. Their contribution to our society is immeasurable, and it is time we matched our words with deeds.

This year’s theme for World Alzheimer’s Day, is “Never Too Late to Make a Change.” It is a clear call to action — a reminder that it is never too late to ensure that every person with dementia in Scotland has their rights respected, their voices heard, and their choices honoured. We are not there yet!

We must continue to advocate for a health and social care system that is worthy of the name — one that is grounded in the principles of fairness, equity, and rights. We must push for a social care and health system that does not treat dementia as an afterthought but as a priority, ensuring that everyone, regardless of where they live, receives the care and support they need.

And we must never lose sight of the fact that behind every statistic is a person — a person with dreams, desires, and a deep need for connection, belonging, and love.

We strive every day to create communities where dementia is met not with fear, but with compassion; not with silence, but with advocacy; not with resignation, but with hope.

Let today be a reminder that it is never too late to make a change, to be kinder, to be more inclusive, and to ensure that every person living with dementia has the chance to live life to the fullest.

Regular readers will know I’m in a Jackie Kay mood at the moment as I re-visit her poems. One that has always spoken to me about memory and loss and about my own family dementia story is her poem ‘Keeping Orchids’. In this poem she has written poignantly about identity, family, and the fragility of memory, which when I first read it resonated deeply with the experience of dementia.

The reference to flowers that hold onto life and memory, buds that remain closed like secrets, served for me at least as a metaphor for the complex, often fragmented experience of memory and identity in dementia.

‘Keeping Orchids’

The orchids my mother gave me when we first met

are still alive, twelve days later. Although

 

some of the buds remain closed as secrets.

Twice since I carried them back, like a baby in a shawl,

 

from her train station to mine, then home. Twice

since then the whole glass carafe has crashed

 

falling over, unprovoked, soaking my chest of drawers.

All the broken waters. I have rearranged

 

the upset orchids with troubled hands. Even after

that the closed ones did not open out. The skin

 

shut like an eye in the dark; the closed lid.

Twelve days later, my mother’s hands are all I have.

 

Her voice is fading fast. Even her voice rushes

through a tunnel the other way from home.

 

I close my eyes and try to remember exactly:

a paisley pattern scarf, a brooch, a navy coat.

 

A digital watch her daughter was wearing when she died.

Now they hang their heads,

 

and suddenly grow old – the proof of meeting. Still,

her hands, awkward and hard to hold

 

fold and unfold a green carrier bag as she tells

the story of her life. Compressed. Airtight.

 

A sad square, then a crumpled shape. A bag of tricks.

Her secret life – a hidden album, a box of love letters.

 

A door opens and closes. Time is outside waiting.

I catch the draught in my winter room.

 

Airlocks keep the cold air out.

Boiling water makes flowers live longer. So does

 

cutting the stems with a sharp knife.

 

Keeping Orchids by Jackie Kay – Scottish Poetry Library

Photo by Kyla Flanagan on Unsplash

Donald Macaskill