It was Alcohol Awareness Week at the start of the month and during it I was reading some of the latest research and data on alcohol and older age in Scotland. It was both disturbing and yet sadly predictable.

Across Scotland today one of the hidden harms of alcohol is its impact on the lives of older Scots and their families and the relative lack of specialist social care provision to address that crisis. This growing issue is not only a personal tragedy for those affected but fractures too many families and communities. It is also a harm which as I’ve reflected upon last year in this blog space we still remain poor at calling it out and resourcing the change that’s needed.

Alcoholism among older adults is often overshadowed by other public health concerns. However, the statistics tell a worrying story.

Research indicates that alcohol misuse among those over 65 in Scotland is on the rise, exacerbated by factors such as loneliness, bereavement, and physical health problems. Unlike younger drinkers, older adults often face more severe health consequences from alcohol misuse, making early intervention and support crucial.

Health data indicates that a significant proportion of older adults consume alcohol regularly, with a notable segment drinking more than the recommended guidelines.

The 2022 Scottish Health Survey indicated that 24% of men and 13% of women aged 65-74 drink more than the recommended weekly alcohol limit (14 units per week). For those aged 75 and over, these figures are 16% for men and 8% for women.

In addition, data from the Information Services Division (ISD) Scotland reveals an increasing trend in alcohol-related hospital admissions among older adults. In the past decade, there has been a marked rise in admissions for alcohol-related conditions such as liver disease, falls, and cognitive impairment. ISD Scotland reported that in 2021, there were approximately 2,300 alcohol-related hospital admissions per 100,000 population for those aged 65 and over, a significant increase from previous years.

And further National Records of Scotland recorded 467 alcohol-specific deaths in 2022 among individuals aged 65 and over, an increase of 15% compared to 2021. Statistics show that individuals over 65 have higher alcohol-specific mortality rates compared to younger age groups, reflecting the severe health impacts of prolonged alcohol misuse.

Older adults struggling with alcoholism face a unique set of challenges. Physiologically, the aging body is less capable of metabolising alcohol, increasing vulnerability to its effects. This can lead to a range of health issues, including liver disease, cardiovascular problems, and cognitive decline. Moreover, alcohol can interact dangerously with medications commonly prescribed to older adults, compounding health risks.

Socially, older adults may experience isolation and loneliness, which can drive them to use alcohol as a coping mechanism. I’ve known too many times where the loss of a spouse, or retirement, or relocation has led to folks turning to the drink in older age. All this can sever social ties, leaving individuals even more vulnerable and the stigma associated with alcoholism can further isolate them, making it difficult to seek help.

The rise of alcoholism among older adults has profound implications for social care in Scotland. More and more frontline workers especially in homecare are telling of noticing an increase in alcohol addiction. They are often the first to notice the signs of alcohol misuse, such as frequent falls, memory lapses, or neglect of personal hygiene. However, recognising these signs can be challenging, as they are often attributed to aging itself rather than alcohol use.

Care providers face the complex task of managing the immediate health needs of these individuals while also addressing the underlying issue of alcoholism. This dual challenge requires a nuanced approach that combines clinical care with psychological and social support. In other words, the response has to have social care at its heart.

The data underscores the growing need for targeted interventions to address alcohol misuse among older adults. The current system is stretched to a point that it struggles with the majority and is failing to pick up this growing demographic and their acute needs.

Social care providers must be equipped with the knowledge and resources to identify and manage alcohol-related issues effectively. Investment at this level will support preventative work and will thus reduce the growing pressures on hospitals and residential care settings.

However, social care workers require specialised training to effectively support older adults with alcoholism. This includes understanding the signs of alcohol misuse, managing withdrawal symptoms, and providing compassionate, non-judgmental care. Without adequate training and resources, care providers will struggle to meet the complex needs of this population.

Addressing alcoholism among older adults in Scotland I believe requires a multifaceted approach, including:

Awareness and Education: raising awareness about the issue is the first step. This includes educating the public, care providers, and policymakers about the signs of alcohol misuse in older adults and the unique challenges they face.

 Integrated Care Models: developing integrated care models that combine medical, psychological, and social care support is essential. This holistic approach can ensure that older adults receive comprehensive care tailored to their specific needs.

Community Support: strengthening community support networks can help reduce isolation and provide older adults with the social connections they need to combat loneliness. Yet sadly we are cutting back and defunding these programmes at a time of real need and acuity. Community programmes that offer social activities, peer support, and outreach can play a crucial role in prevention and early intervention.

Policy and Funding: it’s perhaps stating the obvious but national and local government in Scotland must prioritise funding for programmes and models that address alcohol misuse among older adults. This includes investing in training for social care workers and expanding access to treatment and support services.

Alcoholism among older adults in Scotland is a pressing issue that demands our collective attention and action.

The data on alcohol misuse among those over 65 in Scotland paints a concerning picture of a hidden crisis that requires urgent attention. By acknowledging the prevalence and impact of this issue, we can better support our older population through targeted interventions, comprehensive care models, and robust community support. Addressing this challenge is not only a matter of health but also of dignity and quality of life for our older citizens.

It is a challenge that intersects with the very heart of social care, impacting both those who suffer from alcohol misuse and the professionals who support them.

Let us not turn a blind eye to this issue. Let us confront it with compassion, understanding, and a commitment to creating a social care system that supports every individual, at every stage of life.

Donald Macaskill

Photo by Thomas Picauly on Unsplash

Whether it’s Efcharisto, Danke, Gracias, Merci, Takk or simply thank you – wherever those who can and choose to travel or holiday this summer doubtless most of us will learn the basics of communication in the native language of the place we find ourselves in.

Saying thank you to show gratitude is an important part of etiquette in almost all cultures. Whilst manners might change and customs will divert there remains a truth that learning the vocabulary of gratitude is the first step to properly showing your appreciation in a new community.

I think the same can be said of the busy world of social care. Amidst the daily routines and pressing challenges, there lies a profound yet often overlooked practice: saying “thank you.” These two simple words carry immense weight, embodying gratitude and recognition, fostering a culture of appreciation that is vital for both care and support workers and those they support.

Saying thank you might sometimes feel like an afterthought, a perfunctory nod to social etiquette. Yet, these words carry an astonishing power. In my years of working in social care and beyond, I’ve seen firsthand the profound impact that genuine gratitude can have on individuals, relationships, and communities.

At its core, social care is about human connection. It’s about seeing the person behind the condition, label or stigma; it’s about understanding their stories, their struggles, and their triumphs. In such an environment, gratitude is more than just a courtesy; it is a cornerstone of human dignity and respect.

For social care workers, the role they play is both physically demanding and emotionally taxing. They provide support, comfort, and companionship to individuals who often face significant challenges.

This work can be deeply rewarding, yet it can also lead to burnout if not balanced with adequate support and recognition. The central focus of that recognition has to be the continued struggle to give people adequate terms and conditions – and I hope all governments and organisations will heed the criticality of improved pay for the social care workforce as the primary mark of saying thank you!

However wider acknowledgment of the work of a carer is crucial for individual mental health and job satisfaction.

The act of expressing thanks does not just benefit the recipient; it also positively affects the giver. Research shows that practicing gratitude can enhance well-being, reduce stress, and increase overall happiness. In a field as challenging as social care, where the emotional demands are high, cultivating gratitude can serve as a buffer against burnout and compassion fatigue. This is true at all levels of organisations and communities.

For gratitude is not just a social nicety; it is a fundamental human need. Philosophers, psychologists, and spiritual leaders have long extolled the virtues of gratitude, recognising it as a cornerstone of human well-being. Saying “thank you” acknowledges the efforts of others, affirming their value and fostering a sense of connection and mutual regard.

In social care, where the heart of the work lies in human connection, saying “thank you” is more than good manners—it’s a vital practice that sustains the spirit and dedication of caregivers. It strengthens relationships, builds trust, and fosters a culture of mutual respect and appreciation.

In our increasingly disconnected society, where digital interactions often replace face-to-face encounters, expressing thanks has never been more crucial. It bridges the gap between us, reminding us of our shared humanity and interdependence.

So I’m pleased that Thank You Day is returning tomorrow.

Thank You Day began with a handful of organisations looking for a way to enable us all to say a huge ‘thank you’ to everyone and everything that helped us through the COVID-19 pandemic.

Since then the campaign has grown to include hundreds of partners and over 20 million people have taken part in Thank You Day celebrations. Last year 74% of those who took part in a Thank You Day event said they felt a stronger sense of belonging to their local community as a result.

The celebrations this year are focusing on giving thanks to our local communities.

At their heart is the act of gratitude which creates and nurtures the wellbeing both of individuals and communities and not least those who require care and support.

Two simple words – thank you – a powerful act that can transform our interactions and relationships. It is a small gesture with a huge impact, fostering a culture of appreciation and respect.

I hope you have a summer where you are able to both receive and give thanks.

Donald Macaskill

I first knew Jane when we were both in our early twenties. She and her husband had just suffered a bereavement. Their little girl had contracted meningitis and had died within hours of reaching hospital. They were both devastated, searching for sense through the darkness of their despair; looking for any answer to the thousands of questions they had, all of their conversation tumbling out from their tears and sobs. I was there to listen and be present and to help them as much as I could.

I remember so many of those conversations with folks who had suffered the death of a child or baby – even if I’ve forgotten the names involved – or in truth I remember the feelings I was left with rather than the words. Feelings of utter uselessness in the presence of another’s brokenness.

I met Jane again years later and maybe understandably I didn’t recognise her at first. We had both changed, and we were not the people we were once. One thing she said though has stayed with me ever since. We talked about that first time we had met and about her little girl. Jane said to me “I’ve held her inside every step of the way.”

She told me of how it was really hard to go back home, the emptiness she felt and her desperation not to let go of anything belonging to her daughter – almost she said as if throwing anything away would be an act of betrayal. She told me how she’d visited the grave every day – how she just wanted to continue being a mum; she shared very openly about her attempts to hurt and harm herself because she simply wanted to be with her daughter.

All of this led to the breakdown of her marriage as her partner in her own words gave her ultimatum upon ultimatum as he tried ‘to drag her back into living.’

Then over time she said things started to change. Slowly at first – small steps but important ones. She started working again after 3 years; she began to go out and reconnect with friends; she reduced the time she spent at the grave and on some days chose not to go. She then after a while started dating and met someone.

As she told me of her marriage, of the birth of a son, of his first day at school, of his growing into a man and his graduation, after every story of her growing family and ageing self she said that at every moment of memory that she had held her wee girl inside her every step of the way.

I thought of Jane and her life of unforgetting love when I discovered that next Wednesday 3rd July that it is to be National Bereaved Parents Day.

The day was set up four years ago by the charity A Child of Mine, after they realised that there wasn’t a specific day that honoured bereaved parents from all walks of life. In their words:

‘National Bereaved Parents Day brings together anyone affected by the death of a child to show bereaved parents that they are not alone. This year’s theme is “Love Lives On”.

And how true that statement was and is for Jane.

Over the years I have been privileged to have spent time with people who have been bereaved and each and every encounter has been special. But I have found that the impact of the death of a child on parents has been one of the hardest of all experiences. It is a loss that lives with the parents throughout their time. It doesn’t diminish it just changes.

But what especially saddens me are the countless folks I have talked to in late and older age who are still mourning for a lost child or baby. It saddens me not because they are mourning or grieving but because in years gone by their loss was never validated, often ignored and rarely understood. Thankfully things have improved but I’m not wholly convinced that society doesn’t still expect us to speedily ‘ get over it.’ I’m not convinced that we are not still in a situation where it’s assumed that in your eighties or nineties that the grief for a child dead for decades should now be passed and forgotten. I’ve met too many in care home and community who have never had the chance to grieve and mourn, who have never been enabled to say a proper goodbye.

The death of a child remains with parents for ever – the love does not diminish. We all of us need to be much more aware and sensitive to the particular impacts of such bereavement. In fact in older age, it is often the case that parents may experience a resurgence of grief, particularly during milestones such as anniversaries or what would have been significant birthdays. As others see their children grow into adulthood and milestones like marriage or grandchildren arrive the painful longevity of grief touches ever sharper.

Older adults have often talked to me not least of the child who has died was an only child of how alone they feel as they age. Many older people as they age often face a shrinking social circle due to the deaths of peers or reduced mobility. But the absence of their child can amplify feelings of loneliness and isolation. Without their child to share memories with or support them, parents may struggle with a profound sense of emptiness.

I’d also want to highlight that parents can lose their child at any age and all that I’ve said about grief is as valid for the loss of an adult child as much as for a younger child. But added to the grieving is the possibility that if the deceased child had their own children, grandparents may take on the dual role of supporting their grandchildren while navigating their own grief. This responsibility can be emotionally and physically taxing, especially as they age, impacting their ability to cope and their overall well-being.

Every step of the way, every moment we age, every occasion and memento moment Jane and others will carry their child deep inside their heart. They will never be forgotten; the fracture will never truly heal. Love lives on even if its rhythm alters.

As a society I think we must do more to understand and acknowledge the particular aspects of losing a child at any age both for the parents and for others. We too need to find ways in which collectively and as communities we learn to carry the memory of those who are departed as we age together.

I leave you with a beautiful poem for all ages by the American animator and songwriter Rebecca Sugar called Time Adventure.

‘Time is an illusion that helps things make sense

So we are always living in the present tense

It seems unforgiving when a good thing ends

But you and I will always be back then

You and I will always be back then

If there was some amazing force outside of time

To take us back to where we were

And hang each moment up like pictures on the wall

Inside a billion tiny frames so that we could see it all, all, all

It would look like: will happen, happening, happened

Will happen, happening, happened

And there we are again and again

Cause you and I will always be back then

You and I will always be back then’

Donald Macaskill

Photo by Nick Fewings on Unsplash

Yesterday I was pleased to take part in a Royal Society of Edinburgh session on the challenges facing those who live in rural and remote parts of Scotland as they relate to health and social care delivery. As part of the ‘Islands, past, present and future’ event series it was an attempt to spotlight the stories of Scotland’s Island communities, looking back, taking stock, and imagining the future.

The remote and rural parts of Scotland, not least our island communities, face many of the same challenges which social care provision is experiencing in other parts of Scotland but are doing so with an intensity and immediacy which may not be wholly evident elsewhere. But they also I believe have the capacity and ability to mirror and illustrate for the rest of us some of the pragmatic solutions and potentials for change which we all need to reflect upon and consider into our future.

So what are the challenges and issues?

Geography

Stating the obvious the first and foremost is geography. I am mindful that you define remoteness from where you are – and that it is a very subjective concept. This geographical remoteness impacts on the experience of people who might want to access services but also on organisations who might be willing to provide these. There are fewer services and supports available, reducing the importance of choice and personal control, and also making access to some services challenging because of the sheer distance. I think in particular of the huge number of care homes which have closed in my own island community of Skye where about 20 years ago there were well over a dozen and now only a handful.

A key additional factor both in terms of physically getting to care services and also as it impacts on the ability of staff is the issue of transport or perhaps more the lack of robust co-ordinated public transport together with the cost of self-transport in terms of fuel etc.

Workforce

A related major challenge facing providers is the availability of a skilled workforce. Even without mentioning the ‘B’ word and the hugely damaging impacts of Brexit on rural social care workforce recruitment, it was still immensely difficult for rural and remote provision to attract an available workforce. This is for a huge number of reasons, isolation, lack of support, availability of social housing, cost of living and so on. As hospitality and retail have become more attractive especially during what increasingly feels like a ‘whole year tourist season’ then it has become really hard to sustain workforce levels in social care. So what provdiers end up doing is using agency staff. The exorbitant cost of this emergency provision soon becomes unsustainable.

Since 2022 and the introduction of the Social Care Workers Visa there has been a not insignificant increase in inward attraction to both island and rural communities, but the death knell to such positivity has been sounded by the Tory Government’s restriction on dependents of workers here on a visa.

There are other factors which are evident in island and rural communities. One clearly is demographic – I am not the first nor will I be the last to fear what one newspaper called the new ‘Highland Clearances’ – with an increasing trend of younger people leaving island communities and more townships and communities losing the essentials of infrastructure and community. Added to that is the fact that proportionately the population is older and that this increases demand at a very time when that demand cannot, or it is very difficult to meet. Our islands attract many older individuals who choose the locations in which to retire, and this has and is putting tremendous strain on services when inevitably the ageing process leads to an increased demand.

Increasingly elsewhere when faced with increasing demand, workforce shortage and fiscal challenges both commissioners and providers of social care have turned to technological and digital interventions. Before going much further I would want to declare that I strongly believe such solutions have a place but only alongside humanistic presence and care delivery not as a replacement for and crudely as some sort of cost-saving strategy. But whether it is the increasing use of Ai, of in-house smart devices to monitor acuity and so much more, or simply data and record management, never mind the potential of robotics there are obvious challenges including digital connectivity, technological infrastructure robustness and access, digital poverty and so much more which are potentially faced by island and rural communities.

And of course, the elephant in this island room is economic limitation, lack of investment and the raw reality of rural and island poverty which affects everything not least the availability of social housing – though I was delighted to read this week that the island of Rassay off Skye has after over a decade finally got some more social houses!

Personally, I believe that if our island communities are not just going to maintain themselves in some sort of Celtic aspic then they need focussed and urgent national investment – an Islands Fund! We need social care providers for instance to have a fiscal weighting that enables them to be sustainable in the delivery of services given increased workforce, housing, infrastructure, commodity and related costs.

So the challenges are not insignificant but I also think the potential is equally capable of addressing and overcoming these. Addressing the challenge of social care in island communities requires a multifaceted approach, including improved funding, targeted recruitment and training initiatives, infrastructure development, and the integration of innovative care models. But it can be done and is being done.

Take workforce as an example. NHS Highland is currently funding my own organisation in appointing someone to a post as a Sector Career & Attraction Lead for Care Homes in North Highland. It is a new post yet the post holder Laura Dobinson who comes with a rare blend of sector knowledge but also recruitment and HR skills is working to develop new and innovative approaches to recruit working with local communities to achieve real people into real roles. This is the first post of its kind in Scotland and is already bearing fruit. I hope we will see more of focussed and targeted approaches like this one rather than relying on some of our more traditional methods.

Key to enhancing recruitment has to be a whole system approach – there is no point in having a work ready carer if she or he cannot find a house to come into the island and live in.

But as well as workforce we must look at innovative ways of working. At the heart of this is what already happens in our island communities and that is a degree of integrated and collaborative, whole system working that is the envy of others and is I think the only way forward. Islanders cannot afford the luxury and fantasy of silo working. People who require care and support don’t care a toss about the uniform you wear, the organisational badge you work under, what they want is immediate, professional care and support and a level of continuity, consistency and quality which is the heart of all person-led care and support.

But perhaps we also need to build on the communitarian and co-operative strengths of our island communities, not in a romantic sense but in practical realistic ways.

Communities whether rural, remote or urban, will increasingly have to look after one another more – and as a community is nothing more or less than a collection of individuals – that means we all have and increasingly will have an individual responsibility to ‘be our sister’s keeper’ and look out for one another, care and support one another. Put simply if we do not then no one else will not least given the global ageing, health and care dynamic we will increasingly face.

There are insights and lessons of how we can achieve this all over the world – and if nothing else at least in my experience of having seafarers in the family islanders are the best folks for having an openness to learning from others.

So whether it is the truly integrated and community based approach with care hubs bringing together healthcare, social services, and community support under one roof and so offering a holistic approach to care and improving coordination between services as has been successfully operated for some time in Tasmania, Australia, or the model in New Zealand where the government offers scholarships and incentives for healthcare and social care professionals to work in remote and island communities, and financially fosters a locally trained and dedicated workforce.

There are global insights to learn from. And one I have got to know is a new community-based approach to working developed by Dr Emi Kiyota who I have been privileged to know and work with.  Emi is an environmental gerontologist. She has taught and published across the world but most of her work is in East Asia, especially Singapore, Japan and the Philippines. She established an organisation called Ibasho and developed a model for delivering care and support led by older people themselves in rural and island communities.

‘Ibasho means “a place where you can feel like yourself” in Japanese.

As Emi says: ‘At Ibasho we believe this is what every person should have as they age – a place to live in safety, comfort and dignity, where he or she is valued as a person full of history and experience.’

‘Ibasho recognizes that people fear two things as we age — social isolation and losing respect from others in society. Our goal is to create a shared future in which aging is not something to fear, but to enjoy, as a respected and valued member of communities across the globe.’

She often uses a quote she found at an elementary school in Bhutan said:

“The time to be happy is now, the place to be happy is here, the way to be happy is to make other people happy.”

I believe a lot of what Dr Kiyoto is doing resonates with the Scottish Gaelic concept of dùthchas. It’s a complex phrase that is often used in many contexts but for me it’s one of the many words that suggest ‘belonging’ – that sense of being at one and at home amongst a community or in a particular location.

When my mother developed dementia the most important thing for her health and wellbeing was staying in place, amongst people and spaces she knew, and listening to the language and tongue of her youth.

We can and we must develop models of community-based support which nurture such belonging. It is less about resource than about aspiration. It needs to be less about systems and regulations, than relationships and priority.

As Emi said once:

“Elders living in grass huts in Africa with children at their feet are often happier than people in assisted living homes with a chandelier over their heads.”

Donald Macaskill

Photo by Asa Rodger on Unsplash

I have had some challenging and hard conversations and encounters in the last few days. Indeed, I would go so far as to say that they have been some of the most difficult conversations I have had in many a while. In reflecting at the end of the week on each of them I cannot but conclude that there was a common thread running through the experience of the folks who shared their stories and insights with me – and that was the fact that each of the people were experiencing trauma.

My first conversation was with the manager of a care at home service who informed me that officials at his local Health and Social Care Partnership had told him that they required to make substantial budget savings and because of that they would be reducing the number of packages of care at home which would be available for him to put his name forward for. He reflected that for the council contract staff that this was just about budgets, and finance and numbers but for him it was a change which put the sustainability of his very organisation into question. And that ‘turned his blood cold’ in his own words because he had been in business for nearly two decades, providing what was considered to be high quality care (according to the Inspectorate) and that he had employed a loyal, dedicated and professional staff. He was hyper-anxious when I spoke to him about the limited options he had available; he was desperate to keep things going not only because he was a key local employer in an area where there were few but critically because what broke his heart was the thought of telling customers and staff that things were going to have to change – dramatically. He was in every sense traumatised by what he saw as a short-sighted decision to make savage cuts to local social care and support. He wasn’t sleeping, felt manic, his blood-pressure was through the roof, and he had an overwhelming sense of hopelessness.

My second conversation was with a frontline care worker whose homecare organisation had like so many in the last few weeks been told by their HSCP that cuts were having to be made. However, in this case the organisation would keep going because it was in an area where the folks were able to buy their care even when the local authority had withdrawn packages of care and support. But the reason the worker was in tears was that she had spent that morning on her round saying goodbye to people she had known for months and in some cases years. She recounted one instance where a lady in her eighties who had declining sight and was virtually housebound had up till then been receiving a daily care and support package but after a ‘review’ this had been cut back by a massive degree. The lost relationship, the friendship, the familiarity and knowledge built up between the pair counted for nothing as the HSCP and its ‘reviewers’ (who had not visited her to tell her of the change) cut her service. The carer was in tears as one by one relationships were fractured not because (in her estimation and professional opinion) the care was no longer needed but that someone, somewhere, had decided it was no longer affordable. She was so very upset… she told me she had been traumatised by her morning.

And in a week which has been the national annual Carers Week with lots of photo opportunities for our politicians, I spoke to the wife of a man who had received care and support for many years because of a degenerative neurological condition. Like hundreds across Scotland, she had been told that her husband’s package of care and support was being reduced ‘after re-assessment’. She was at her wits end as to how she could cope. She was getting frail and older herself and the thought of having to do more for her husband was draining her. She had no family nearby and all her neighbours were either older than her or had their own issues. She desperately needed the support to continue, to get time for herself, to have some respite from caring. Yes, she had an increased allowance, yes she had accessed all the financial support she could, but what she really needed was the daily relief of someone else who knew her husband being present, being there, being for her. Someone else to share her burden and questions and exhaustion. She feels utterly and completely abandoned.

Each of these conversations left a mark on me because it is clear to me in their own way that each person was traumatised and going through trauma because of what was happening in their lives.

I know the response to what I have written will be – especially during an election – to posit understanding and then to cast the blame and responsibility to another – the lack of UK Government funding; the lack of resource from Scottish Government given the level of increased need; the failure of the local decision makers and so on. But to be frank I am tired of the pass the buck mentality and lack of honesty, the failure to own up collectively as a nation, as political leaders, as social care and health leaders, that the system is well and truly broken. And more than that that the decisions to cut care packages, to review and stop, to reduce the number of care beds being occupied or the number of care packages being contracted – all of it has and is traumatising some of the most valuable and vulnerable people in our communities. It is not fair. It is not just. And it is not the Scotland I want to live in.

I am familiar with trauma both as a concept and as a lived reality. We hear a lot of talk in the world of social care about trauma and what has become known as trauma informed practice. Indeed, the latter is now a core element underpinning the latest professional standards from the regulator. More than that Scottish Government guidance states that all social care and related practice should be understood and responded to through a trauma lens.

Trauma can be variously described but a simple definition states that:

“Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as harmful or life threatening. While unique to the individual, generally the experience of trauma can cause lasting adverse effects, limiting the ability to function and achieve mental, physical, social, emotional or spiritual well-being.”

And our trauma informed practice in social care and social work is that which:

“is an approach to health and care interventions which is grounded in the understanding that trauma exposure can impact an individual’s neurological, biological, psychological and social development.”

Social care practitioners and services know what is required to support those who have been traumatised. At the heart of such attention is their physical, psychological and emotional safety and attempting through all means to prevent re-traumatisation for the person being cared for and supported.

Now I recognise that the concept of trauma and trauma-informed practice is not universally accepted and there does indeed need to be safeguards as brilliantly delineated in the recent work of Mark Smith and Sebastian Monteux who have suggested caution in its application ‘lest a  predominant focus on trauma may construct the kind of psychological conditions it professes to respond to.’

But at a very human level what is happening in Scotland to our social care services and supports at this time is resulting in very real trauma, harm and suffering.  Perversely those charged with fostering the delivery of compassionate trauma informed practical care and support are now the agents of re-traumatising a damaged and vulnerable citizenhood.

For the staff and managers I have spoken to there is clear evidence of the trauma they are experiencing resulting in burnout, emotional and compassion fatigue; they are being overwhelmed by resource limitations which are resulting in very acute conflicted values. This level of chronic stress is leading to exhaustion, anxiety, depression and acute self-doubt. It is also for many resulting in what I can only describe as vicarious trauma where the trauma experiences of supported people and those being cared for create a sense of vulnerability and helplessness in the worker and manager.

We urgently need to address the reality which is a traumatised social care system, workforce and those who require social care supports. We cannot continue to do more harm in the name of fiscal and resource re-allocation and prioritisation. There has to be a more honest way of addressing the crisis of social care in Scotland than traumatising those who deliver, work in and use our services.

Donald Macaskill

 

After many requests from not a few the Cabinet Secretary for Health and Social Care, Neil Gray addressed the Scottish Parliament this past week in a speech during which he outlined a vision for health and social care. In his speech he said that:

“I have already outlined to my Cabinet colleagues an overarching vision which will guide our work.

This vision is one with which no one here could argue: a Scotland where people live longer, healthy and fulfilling lives.

This vision is supported by four key areas of work: improving population health, a focus on prevention and early intervention, providing quality services, and maximising access, with all of these underpinned by giving due consideration to the people at the heart of those services.

In the short term we must ensure that our services are delivered in the best way we can within our current arrangements, and in the medium term, we need to begin to transform how we work.

And we must keep our eyes on the horizon, because in the longer term we also need to fundamentally change how we think about the delivery of health and care, driving investment in prevention and early intervention.”

I hardly need to say that those of us who deliver and work in the independent social care sector look forward to being invited to play our part in the shaping of this vision into reality in the short, medium and long term. I very much hope that the stated Expert Reference Group will include those organisations who provide most of the social care delivery because without their expertise then any venture will fail.

Few could disagree with Mr Gray’s vision ‘of a Scotland where people live longer, healthy and fulfilling lives.’ Yet sadly the reality is increasingly one which is quite the opposite and is likely to worsen before it improves.

I was also pleased to hear in the speech the emphasis upon prevention and supporting and caring for people close to their own home. Of this the speech stated:

“This will be underpinned by the principles of accessibility, addressing health inequalities, maximising outcomes, and promoting innovation as well as value for money.”

It was also refreshing to hear of an emphasis on the game-changing nature of technologies – and indeed the social care sector in Scotland is world-leading in the use of such technologies such as wearables, the IOT, Ai and robotics which enable independence and citizen control, albeit that its successes are probably better known outside Scotland than within.

I was reflecting on all this potential for a vision and practical change when I attended a couple of days later the impact and celebratory event of the Leading Digital Transformation in Health and Care for Scotland MSc programme run by the Usher Institute of Edinburgh University in collaboration with NHS Education Scotland and the Scottish Government.

Now into the start of its second year the participants on the programme have been exploring a wide range of topics, ‘from fundamental leadership concerns such as communication and change management, to current critical challenges of the digital age such as systems, interoperability and data sharing.’ It was refreshing to hear some of the 40 plus participants talk openly about how they are tackling real world issues facing those of us in Scotland who access our health and care systems.

It was also inspiring to hear inputs which argued that we need to stop talking about technology as tomorrow’s solution and to grasp the fast-moving pace and reality of innovation which is already making a difference to the health and wellbeing of people – if only we can maximise that potential in Scotland. Sadly I suspect we too often cogitate, ruminate and discuss rather than create, embed and commence.

We have so much we can do better and need to do urgently and in no small way at the heart of our health and social care inequalities in Scotland is the health of men and boys. On Monday (10^th June) we start the annual Men’s Health Week which is an event organised by the Men’s Health Forum. Like the Cabinet Secretary’s vision its aim is very much focussed on preventative health and to encourage men to gain the courage to tackle their issues.

We often talk and reflect on health inequalities in Scotland but surely one of the most primary ones is the fact that one man in five dies before the age of 65 and chiefly from preventable conditions.

So in the coming week there is a focus on prostate health. The week is to be called Let’s Talk Prostates (And Everything Else Men’s Health!) As the organisers state:

“Men don’t talk, we’re told. So, for Men’s Health Week 2024 we’re encouraging men to share their stories.

We’re taking our lead from King Charles who, earlier this year, shared that he had a problem with an enlarged prostate. On the day after his announcement, there were 16,410 visits to the relevant National Health Service website page compared with 1,414 visits the previous day. Prostate Cancer UK saw an almost doubling in the number of users of its online risk checker.

This goes to show the difference that honest sharing can make. Most of us won’t have same impact as the King – for a while in the UK media, it was difficult to avoid urologists talking about the prostate and the things that can go wrong with it – but if there is a taboo about men’s talking, well, the best way to beat a taboo is to ignore it.”

I cannot but reflect on how important it is that the three strands of my week just past  combine – a renewed emphasis on preventative health and social care which focusses on where we are; a practical adventurous use of technology to support our wellbeing and a focus on health inequalities, which for the next week at least is upon men and boys.

Men tend to respond well to health programmes that incorporate digital or technological elements, and yet so little of our actual delivery of healthcare, of public health education, of social care delivery utilises the benefits of technology and digital.

We must get better at reaping the benefits of technologies and digital interventions which appeal to men for many reasons but including because they are more accessible and convenient, because they enable engagement and interactivity, and which can be truly personalised to the individual rather than to treat us as a group of individuals.

We have to utilise the benefits which technology give to us in terms of the delivery of health and clinical and care interventions. Digital and technology are not just offering us tools to inform, increase awareness and knowledge, but also to treat, cure and care.

I look forward to contributing to an emerging vision of health and social care which addresses inequalities, but I am increasingly convinced it has to work in close partnership and collaboration with the technological, digital and Ai communities which are already working to effectively improve our wellbeing both individually and societally, and which have I would suggest to date been untapped in their potential to challenge health and social inequalities.

Donald Macaskill

Photo by Jenny Hill on Unsplash

 

They seek him here, they seek him there

Those Frenchies seek him everywhere

Is he in heaven or is he in hell?

That damned elusive Pimpernel

Famous words from Baroness Emmuska Orczy’s The Scarlett Pimpernel which described the heroic elusiveness of the main character as he managed rescue upon rescue of captured prisoners during the French Revolution.

Being elusive is the heart of the success of the Scarlet Pimpernel. It was a thought that came to mind this week as I reflected two weeks into the campaigning for the United Kingdom General Election about the prominence or maybe more accurately the absence of social care within the election. Now I fully recognise that social care is a devolved matter and that it’s delivery in the Scottish context is obviously the responsibility of the Scottish Government and concerns about it belong to debates amongst Scottish political parties. However, I think the nature of the fiscal relationship between the United Kingdom Government and the Scottish Government is such that whatever is discussed and decided about social care in England does have an impact in Scotland not least of which is any increased financial priority and spend.

So, what has been happening south of the border and indeed across the United Kingdom with regards to social care? Well like the Scarlet Pimpernel I seek some knowledge here,  I seek some knowledge there but the damn elusive social care seems nowhere. Not a mention not a whisper.

Writing in the Independent a couple of days ago Kate McCann said that social care was the issue that Sunak and Starmer won’t touch with a barge pole. Of social care she wrote that it was:

“currently the biggest electoral elephant in the room. It’s no surprise that neither of the main parties wants to touch this policy with a barge pole, after Theresa May tried and found herself tied to the drag-anchor of the dementia tax in 2017 – leading to that now-famous “nothing has changed” moment.”

…

“Problems with the social care workforce have fed into questions about immigration policy. A lack of available care places in the community means hospitals end up caring for people who are medically fit but unable to leave, clogging up admissions at the other end.”

Yet no commitment from Labour’s Wes Streeting to either social care reform or on the Dilnot proposals. Even greater silence from Labour on the impact of immigration on social care workforce sustainability. Only the Lib Dems seem to be actually talking about social care.

As McCann rightly observes of the two main parties:

“Neither is likely to propose wholescale change of the kind for which experts in the sector are calling, demonstrating a lack of ambition from both Labour and the Tories on this issue. There are clear reasons for this – not least the costs – balanced against the state of the UK economy. But, as political reporters, it makes it even more important to cut through the sales pitches and ask the questions that get to the heart of the problem, otherwise we risk serving voters poorly.”

So what of Scotland – well echoing absent silence here too and missed opportunity.

Last Monday Alzheimer Scotland published a report of the Commission on the Future of Long Term Care in Scotland. Set up in 2022 and chaired by former first minister Henry McLeish, the commission brought together a wide range of voices, including health and social care experts and those with lived experience of dementia. I was pleased to serve on the group.

Over the piece we heard first hand of the challenges facing those living with dementia and the lack of provision to enable people to live independently for as long as possible as well as the critical issues of lack of investment which would enable greater diversity and choice in specialist residential provision.

The report makes 16 key recommendations designed to safeguard and redefine the future of long term care in Scotland.

These include calls for the Scottish Government to:

• urgently work with health and social care partnerships to undertake a full strategic assessment of the provision of long term care facilities and resources in each area,
• establish agreed levels of care home and alternative care model places that should be equally available across Scotland,
• establish a citizens’ assembly to engage across society on the type of alternative approaches to care that people want to access to meet their long term care needs
• and engage in open, honest discourse around the reality of the current cost of care.

In commenting on the report I said that:

“Long term care matters for all of us. The way in which residential and nursing care is delivered today will inevitably change over the years. This report makes clear that people want to have a wider selection of choice about the care they may need and that they want more voice and control.

The Scottish Government urgently needs to prioritise social care and has to create an environment where external investment is able to support providers to innovate and develop new models of care and support.

In addition, the time has long passed for the inequity of people living with dementia having to pay for support and care which are essentially healthcare needs. There is so much that needs to change and no shortage of people wanting to support that change. The ball is well and truly in the hands of Ministers.”

So it’s an election – social care is devolved – will our Scottish Government take up the challenge and introduce fairness into the way we support people living with dementia? Will we properly invest in long term care  and support? Will we pay for a sector fit for the future?

Or like Sunak and Starmer with heads in the sand – will both commitment to and real change for Scotland’s long term care sector be as elusive as the Scarlet Pimpernel?

Donald Macaskill

Photo by MontyLov on Unsplash

I am writing this in New York City at the end of a week when I have had the privilege of being an accredited participant at the Open-Ended Working Group on Ageing (OEWG). OEWG has met every year over the last 14 years and was established by the United Nations General Assembly because of a growing clamour from some nations who wanted to see the development of an internationally binding legal framework to protect the rights of older persons. This was nothing new – indeed from the earliest years of the UN Argentina and others had continually campaigned for such a Convention to be created. Yet consistently there had been failed attempts to get it off the ground. OEWG was set up to identify whether there were any ‘gaps’ in existing human rights protections. At various points over the last 14 years, it felt it had done its work only to be sent away again to do more … until this week.

This year in a historic moment on Tuesday a decision was taken ‘by consensus’ to put forward a report suggesting that there were gaps which needed to be filled and to offer some solutions including the creation of a new instrument, a Convention. Yesterday it was decided that this decision should be passed to the UN General Assembly session. So significant progress. I was honoured to be part of the week and to have played a small role in the events by addressing the Session on Tuesday morning. Throughout the week I heard moving and passionate speeches from people who evidenced the harrowing harm and abuse that so many older people are suffering across the world, of the economic harm and abandonment of millions more, and of the desire for millions to be allowed their voice and to find their seat at the table of decision-making and government. But I also witnessed the art of political negotiation, international compromise, vacillating excuse, and blatant national self-interest.

At the end of such a momentous week I am left in a reflective mood about whether or not all this matters. Does any of it have any consequence for the experience of older people anywhere never mind in Scotland. And I am reflecting on all this at a time when a UK General Election has just been called during which I really hope that we will have debates and discussions on the experience of older people and most especially the nature of social care.

In short, I really do believe that for the advancement of all older people and their human rights that an International Convention on the Rights of Older Persons is urgently needed (and I hope the Human Rights Council in Geneva will soon start working on it when the General Assembly so instructs). I would argue that this is the case because as citizens of a global world we cannot but be connected to one another. The passionate Argentinian advocate Alex Kalache spoke of a visit to a favella on the edge of Rio where he stood talking to a woman knowing that 800 metres away the houses of the rich and wealthy meant that their residents were likely to live 20 years longer than the residents of the favella. The old woman Nina asked him ‘Do you know where my parents are?’ And he responded, ‘No I don’t.’ and she said ‘They are underneath your feet. We could not afford to bury them elsewhere, we could not afford it – so they are here.’ This sad encounter is indicative of the grinding poverty and socio-economic injustice which faces many older people; from those who lose their properties when they get old, to those who are abandoned by their families and made homeless because they have ceased to be useful and economically contributive. All of this might seems light years away from our lived experience in Scotland, but if there is anything about the Scottish character that is worthy of acclaim, it is our awareness that we are all ‘our brother and sister’s keeper’, we are all linked to one another in a common humanity and co-responsibility.

We could just rest in Scotland, struggle even more for the rights of older Scots, fight to ensure a better social care system, work for a reduction in discrimination and ageism; we could and will continue to campaign for an Older Persons Commissioner and the rights of older persons to be explicitly evident in any new Human Rights Bill; we could and will continue to call out the economic injustices which treat older people less favourably, to highlight the grinding poverty so many of our older Scots endure. But we also I believe have to do more. Putting our own house in order without sorting the mess of the world in which it is set is simply a retreat from responsibility. Human rights matter for all, everywhere and at all times.

In the coming weeks during a General Election political parties of all colours will engage in an appeal to self-interest – that is almost an inevitability of the political struggle and class. But I earnestly hope that we will also be able to ask questions, make challenges, and raise the voice of those not here but with whom we are global citizens, because what we decide and the government we elect makes a difference to them. Sustainability of our planet is not just an ecological question it is a profoundly demographic challenge and as the population of the world ages the way we address that reality matters.

In my speech at the United Nations, I tried to argue that the creation of a Convention certainly would offer protection for the world’s older people (protection and safeguards which are not there) but that just like the UN Charter in 1948 it also offers us potential. It offers us the ability to recognise the inherent dignity which comes with being old, it offers us the ability to celebrate the giftedness of age with all the richness of its diversity and experience, its creativity and contribution. We have to challenge the ageism which suggests that the old are yesterday’s humans and that the future belongs to a younger generation. Such ageism is rife across the globe. I heard this week that even in a document which is being drafted at the UN about the future – there is barely a mention of the old.

The older generation are as much the future as they have been the past. To deny their contribution, their capacity, their inventiveness, their entrepreneurship, is to limit all our futures. I hope in our own General Election we will not witness such stereotypes and stigma but will witness acceptance that the future belongs to us all, old and young alike. I also hope that our own political parties will come out and clearly state that they are in favour of a UN Convention on the Rights of Older Persons, so that we affirm our belonging one to the other.

During the week I spent some time getting away from the noise and heat of the debate and discussion, the politics and politicking and I wandered around and found a place in front of a painting which had been gifted to the UN by El Salvador in 2019. It was titled Mi Pueblo by Camilo Minero. Minero was a prominent Salvadoran painter, muralist, and engraver. The colourful painting has two themes, one is peace, represented by the light of the sun and the abundance of the natural world. The second theme is human rights, represented in the faces of children, the labouring hands of workers, and the hopeful look of the population that works for a better future.  All living their lives unimpeded under the guarantee of peace.

That should surely be the aspiration of us all, a world where we can live our lives with no discrimination. I am pleased to leave the UN knowing that the struggle for the rights of all including older people lives on but that it is also one that is worth the fight. For me rights matter today more than ever.

Donald Macaskill

The following is based on an address given yesterday at the Scottish Care, Care at Home and Housing Support Conference, ‘Care Revolution: Time to Act’ held In Glasgow.

 

I suspect I won’t be the only one in this room for whom the words of the song from Tracy Chapman were the wallpaper of their teenage years or twenties. First launched in 1988 ‘Talkin’ Bout a Revolution’ became the anthem of disenchanted and disaffected youth and social campaigners at a time of high unemployment, industrial unrest and growing poverty. It was a clarion call not just to be passive and talkative but to do something and to be someone.

The lyrics are illustrative of the whisper that becomes a shout for change:

Don’t you know

They’re talking about a revolution?

It sounds like a whisper

Don’t you know

Talking about a revolution?

It sounds like a whisper

 

Don’t you know

Talking about a revolution?

It sounds like a whisper

 

And finally the tables are starting to turn

Talkin’ ’bout a revolution

Yes, finally the tables are starting to turn

Talkin’ ’bout a revolution, oh, no

Talkin’ ’bout a revolution, oh, no

Talkin’ ’bout a revolution, oh, no

Many of you will know that I love words and languages and their root meanings and in my first language which is Scottish Gaelic the main word for revolution is ‘ar-a-mach’  and is similar to the Latin word revolvere which means  “a revolving,” “turn, roll back”.

All of these have the connotation of return and orientation and so I love the way in which Tracy Chapman‘s song uses the same metaphor that the tables are starting to turn …

Revolutions don’t necessarily mean throwing the baby out with the bath water, of engaging in violent and dramatic destruction and removal of the past. There is no need for any heads to be guillotined in the social care revolution that I want to suggest to you urgently needs to happen in today’s Scotland.

Going back to the way things used to be, a turning of time, is and can be revolutionary in itself and that’s what I think we need in social care not least in-home care we need a turning of the tables – we need a decision and a time to stop what we’re doing and rediscover the essence of what social care and home care is all about.

And why do most revolutions or renaissances or rediscoveries happen? – well usually because people or communities have simply had enough. They become tired of accepting the givenness of things, of settling for third or fourth best, of the status quo which limits and imprisons them.

Whether the civil rights cause in the United States, the disability rights movement of the1970s and 80s, the Dallits or Untouchables in India, – there is a time reached when people say enough – there has to be a better way.

And have we not got to that stage in terms of homecare and housing support in Scotland? Despite the warm rhetoric of political mantra and the delusion of massaged figures and budgets what we have arrived at is a state of affairs that cannot be deemed to be human rights based social care and cannot be seen to embed dignity in the lives of people.

What we have arrived at is a shameful abandonment of the essence of good social care which is about enabling people to be independent, to have control and to manage the living of their lives so that they reach their potential.

What we have arrived at is eligibility criteria set so high that you need to be close to death before you get a package of support, for which it will have taken you weeks and months to get an assessment organised. Then once you do you will get the bare minimum of support.

What we have arrived at is a system stripped of humanity, commissioners arranging an approach to care which is about providing maintenance not furthering life. Keep people alive but no more – and do it cheaper. Let us save money at the cost of living life to the full.

When someone in their nineties gets stripped of the care and support, she has had for 4 years; when someone who is imprisoned in their house by their mental illness has a care package removed with 2 days’ notice; when more and more workers are faced with the impossibility of packing all their compassionate care into 15 minute monitored time slots then …

what we have arrived at is a state of affairs which requires revolutionary change not just a tinkering or a slightly increased budget here and there – we need a re orientation and a rediscovery of the essence of who we are as one another related in our common humanity.

That’s why we need a care revolution and I’m sorry but I simply do not believe that the mechanistic reorientation of the system also known as the plans for the National Care Service will bring that revolution about.

But for a revolution to succeed we do not just need anger and frustration. We have that in abundance. We don’t just need a desire to change for the sake of change – but revolutions firstly succeed when you have a vision of what you want to become as an individual or as a society. And secondly, they succeed when causes are able to garner sufficient support so that there is a collective desire to change the way things happen.

And of those two starter ingredients we have the vision – we don’t need to search or look for it. It’s in the very description we have of social care at Scottish Care – it’s in our DNA – it’s about people being supported to lead the lives they want and need to – it’s in every report we have ever written about homecare.

Homecare as:

‘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.’

And how do we create a collective? – well for home care that means the coming together not just of those who work in the sector, not just organisations which deliver care and support, but all people in our community, not just those who receive care and support and their allies who are themselves drained and exhausted and so often without the energy to fight, to struggle for more than themselves and their loved ones.

We need Scotland to waken up – we need the tables to turn – we need a care revolution so that it becomes the concern of every person, every community, every politician and every individual who considers humanity to be of worth.

We have to stop fighting in our own patch, sometimes sniping at one another, we have to collectively come together and organise. We have the vision – we have the dream – it’s time to act – and the time is now.

But any journey needs strength especially to make that first step – to go outside of the known and venture towards an uncertain future.

I truly believe there is an inevitability that compassion will win out over contracted concern, that reality will replace rhetoric, that possibility can become the norm, that dreams and visions can become the familiar and the ordinary of our lives.

 One of my favourite singers who is very different to Tracy Chapman is the 1960s singer Judy Collins and one of her most poignant and beautiful songs was one that she sang having heard it first from Pete Seeger -a man who knew more than a bit about revolutions and change – who wrote the music to some very well-known ancient religious lyrics – You might also know the version by The Byrds.

To everything there is a season

To everything (Turn, turn, turn)

There is a season (Turn, turn, turn)

And a time for every purpose under heaven

A time to be born, a time to die

A time to plant, a time to reap

A time to kill, a time to heal

A time to laugh, a time to weep

To everything (Turn, turn, turn)

There is a season (Turn, turn, turn)

And a time to every purpose under heaven

A time to build up, a time to break down

A time to dance, a time to mourn

A time to cast away stones

A time to gather stones together

 

To everything (Turn, turn, turn)

There is a season.

 

For social care and for homecare there has to be a season,  this is it,

a season of revolution, a return to care without calculation, to times when relationships mattered more than records, when compliance wasn’t a monitoring system but the relationship between supported person and carer.

a season for everything under the sun

the time is coming when the tables will turn

 

when the talk of revolution will result in change

because the season of compassion, the season of care, the season of regard, the season of prioritising support for all has surely to come.

Enjoy being the care revolution in season and out.

 

Donald Macaskill

 

 

Donald Macaskill

The following extended blog is based on an address given to staff at Erskine Veterans on Friday 10^th May, in celebration of International Nurses Day which is held every year on the 12^th May, the birthday of that original nursing pioneer Florence Nightingale born some 204 years ago.

The theme for this year’s International Nurses Day 2024 is ‘The economic power of care’ which might seem at best a bit of a tangential topic but when you reflect on it, I think, makes complete sense.

I want to share some reflections this morning on this theme and to do so in three strands:

• What did money mean to Florence?
• The economics of nursing care, and why I believe,
• Social care nursing has a particular and unique contribution to make to economic and wider societal wellbeing.

I think it is fair to say that Florence came from a relatively well-off family. She was the second daughter of a prominent family, and her father William was a successful banker. The family owned properties in Hampshire and also an estate in Derbyshire. Like many wealthy individuals of the age, they had a large number of servants and staff. What was more unusual was that William insisted that his daughters had an education, and they were schooled in science, history and mathematics.

Florence was a religious child even by the standards of the age and from an early age she had decided she wanted to in her own words ‘alleviate suffering’ and to do so she decided to become a nurse. At the time nursing had a very low social status and the idea of someone from a wealthy background who simply did not need to work, becoming a nurse seemed unthinkable. It certainly was to her father William who resisted the protestations of his daughter. But like many fathers might recognise he eventually gave in and in 1851 he agreed that she should attend a school for women in Germany where she learnt core patient skills.

Two years later Florence was improving the treatment of patients at a women’s hospital in London. Then the war that changed nursing started. The Crimea War broke out in 1854 and British troops went off to fight in the Crimea – an area in the south of Russia, now part of Ukraine. When news reached the Minister for War, Sidney Herbert that hundreds of men were dying from their battle wounds and diseases he asked Nightingale to lead a team of nurses and go to the Crimea.

Her frontline heroism, her emphasis on hygiene and cleanliness, her transformation of hospital conditions became legendary and modern nursing really started.

After the Crimean War Nightingale was awarded a huge sum of money – over £250,000 from the British Government and in 1860 she used the money to establish the Nightingale Training School for Nurses at St. Thomas Hospital in London. Indeed, during the War in 1857 a fund was set up to support Florence’s work and it raised £44,000 equivalent to £2 million pounds today.

If you read her many letters and the histories and biographies produced over the years you can’t help but be struck by the fact that here is a woman who had economic and financial savviness, and knew the cost of things to the penny but she was always confident that she could raise the money needed in order to focus on what was paramount in nursing – the patient. Indeed, she is quoted as saying that ‘I attribute my success to this – I never gave or took any excuse.”

Money was a means to an end; its absence or lack could not or should not be used as an excuse for poor patient treatment or poor nursing skill and education. And ever since the Florence Nightingale Foundation has invested millions of pounds over the years to improve and advance the quality of care and nursing across the globe. And still does so today.

So, I think Florence teaches us our first lesson on economics and nursing – namely don’t let economic excuse or fiscal challenge become the reason for inaction.

In our modern era then what do we mean by the economics of care?

When the International Day of the Nurse theme was decided it was declared with the statement that ‘nursing creates healthy people and societies and drives healthy economies.’ In other words, there was an assertion that to have a healthy economy you need to recognise the contribution of nursing to societal and national wellbeing and health.

But when the ICN President, Dr Pamela Cipriano explained the reasoning behind the chosen theme, she also issued a warning:

“Despite being the backbone of health care, nursing often faces financial constraints and societal undervaluation … ICN has chosen to focus IND 2024 on the economic power of care with the aim to reshape perceptions and demonstrate how strategic investment in nursing can bring considerable economic and societal benefits.

We believe now is the time for a shift in perspective. We have seen time and again how financial crises often lead to budgetary restrictions in health care, typically at the expense of nursing services. This reductionist approach overlooks the substantial and often underemphasized economic value that nursing contributes to health care and society as a whole.”

Couldn’t be any clearer – if you want a healthy society then invest in nursing and what it brings to the health and wellbeing of that society. When times are tough and economies are struggling it is NOT the time to disinvest or draw back – quite the opposite – it is the time to prioritise in a profession which enables people to remain healthy (especially in austerity); it is a time to ensure that nursing continues to support people who want to and are able to remain part of their communities and who can then contribute themselves to the economic and social wellbeing of their place.

We very rarely view nursing as an economic contributor – we tend to be uncomfortable with that sort of language – but I think we need to get real and recognise that without the daily contribution of nurses up and down our country, then the functioning of our society and economy would simply over time grind to a halt.

It is especially the case in a country like Scotland that nurses enable communities to thrive and people to flourish, and where they contribute to our wider societal wellbeing and health. It is because of nurses that communities live better, and we are all able to become healthier. Without nursing the horrendous health inequalities of our country would become even worse and deeper.

My third strand for the economic contribution of nurses – is what I consider to be the distinctive, unique and particular role of nurses who work in social care settings and contexts.

There is a very active debate about what it is that is special or unique about social care nursing. I am not the only one in this room I suspect who has been reading a lot of threads on Twitter or X and Facebook discussing what a difference social care nursing makes.

There seems to be nothing new in this… more of that in a minute… But here are three descriptions: (so you know what it is that you should be doing.)

‘Nurses in social care have distinct expertise. They use their clinical skills to understand the variety of needs of patients, and also deliver relationship-centred support. They recognise the importance of giving each individual a sense of security, purpose, achievement and significance.’  NHS England

The distinct expertise of this group of registered nurses is in enabling individuals with care and support needs, many of whom have multiple co-morbidities and complex health issues, to live positively in their own homes. They embody the capabilities and cultures of both health and social care professions and employ their nursing knowledge and skills within a social model of care. Their focus is not only on an individual’s health condition and resulting impairment but also on the impact this has on their participation in social and community life.  Skills for Care

​A healthcare need is related to the treatment, control or prevention of a disease, illness, injury or disability. And the care or aftercare of a person with these needs. A social care need is focused on providing assistance with the activities of daily living.’  MIND

My former colleague Dr Jane Douglas researched and wrote a brilliant report which was published two years ago. It stated that:

“While participants to the study struggled to define the role of nursing, they were able to clearly articulate the knowledge and skills required to undertake the nursing role in care homes, along with the value of having Registered Nurses. They easily reflected on how they use their own knowledge and skills to ensure residents in their care remain as well as they can.’

It went on to say:

‘The Social Care Nurse focus is to ensure better outcomes for people experiencing care and their relatives, to ensure a quality of life and a quality of death. To support the person to be as well as they can with the understanding that wellness fluctuates daily. This is achieved through a holistic person-centred approach.’

That definition and the findings of her report in part grew out from and drew upon a Twitter debate about the distinctive role of social care nursing. And lo here we are again two years on and we are still debating what is distinctive and special, unique and particular.

But the very fact that there is need of a conversation in the first place tells its own story about the under-valuing, the stigma and the marginalisation of social care nurses. I find it astonishing that there is such a high level of ignorance amongst nurses who have never worked in the social care sector about what it is that their colleagues and fellows do. I find it shameful that there are so many instances of casual dismissiveness that suggest that social care nurses are folks who are wanting an easy life away from the hard work and grind of the acute hospital ward; I find it demeaning that there is so little understanding of the ultra-professionalism, astonishing levels of skill and autonomy that exists in the care home sector.

Can you imagine that surgeons in different disciplines would so easily dismiss a colleague or worse than that would not even consider that it was worthwhile that they should know the scope, expertise, clinical ability or patient insights of a colleague.

Maybe we have got it the wrong way around – rather than social care nursing having to defend its position, propose a theory of its uniqueness and posit its distinctiveness – maybe our colleagues in the NHS can tell us what is so special about the jobs that they do that all others in social care should be so casually excluded from value and appreciation, from recognition and notice?

In the theme of the day perhaps more than any other form of nursing it is social care nursing that helps turn the wheels of our economy. It enables people to be supported and nurtured so that they can continue to contribute. It nurtures relationship, fosters community, attends to not just the clinical needs but the holistic requirements of a person in community.

Social care nursing has to re-discover the spark of passionate identity which Florence Nightingale fostered – for if nothing else it strikes me when you read the works of Nightingale that it is social care nursing that seems closest to her original person-led, relationship based, autonomous understanding of nursing from life through to death. In social care nursing we get Florence’s sense that nursing was not an added extra or luxury, but an essential ingredient which bound our common humanity together especially to those who were wounded or ill, broken or fragile.

Florence once said:

“The world is put back by the death of everyone who has to sacrifice the development of his or her peculiar gifts to conventionality.”

It is time for social care nursing to stop being put back by dying to be defined … we should not be continually having to defend a definition but rather need to proclaim the irreplaceable benefits, the peculiar gifts, that the women and men in this room and outside across Scotland’s care homes and social care organisations are bringing every single minute of every single day.

Happy International Nurses Day when it comes.

Donald Macaskill