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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Stroke

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

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

her hand cold-numb below the eiderdown…

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

And still my mother didn’t answer.

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

Donald Macaskill

Today, October 18, is World Menopause Day.

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

But awareness is only the beginning.

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

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

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

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

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

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

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

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

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

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

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

This is not marginal. It is central.

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

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

She Loves Me, She Loves Me Not

She loves me.

By day she sits, quietly, by my side.

My night cool and restful.

She loves me not.

She laughs mockingly in my face.

And it burns.

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

I’m a rabbit caught in the headlights.

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

She’s packed away my self-esteem.

My courage fails me.

Meltdown.

The night brings no solace.

Her furnace stoked.

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

I’m stuck on repeat.

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

That my hormones will, eventually, settle down.

Bring on that day.

 

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

 

Donald Macaskill

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Remember

Christina Rossetti

 

Remember me when I am gone away,

Gone far away into the silent land;

When you can no more hold me by the hand,

Nor I half turn to go yet turning stay.

 

Remember me when no more day by day

You tell me of our future that you planned:

Only remember me; you understand

It will be late to counsel then or pray.

 

Yet if you should forget me for a while

And afterwards remember, do not grieve:

For if the darkness and corruption leave

A vestige of the thoughts that once I had,

Better by far you should forget and smile

Than that you should remember and be sad.

 

Donald Macaskill

 

Photo by The Good Funeral Guide on Unsplash

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Realism tells us that social care is at breaking point.

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

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

That is the hope we must build upon.

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

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

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

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

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

Reform means:

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

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

As the poet Hugh MacDiarmid once cried:

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

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

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

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

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

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

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

Implementation is where aspiration meets accountancy.

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

Implementation requires:

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

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

Let me put it in five imperatives:

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

I want to finish as I started with a story.

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

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

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

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

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

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

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

Donald Macaskill