It is time for the frail to weather well:  a call for positivity in ageing.

Three weeks ago, I wrote a blog on the nature of vulnerability – both challenging the misuse of the word and also suggesting the need to develop a more positive view of vulnerability. With a degree of synchronicity and similitude, I have been having comparative conversations with clinicians and colleagues in the last few weeks over the concept of frailty.

Frailty has been a key concern for the care sector for many years. Over that time there has been considerable discussion about its definition, what it means both physiologically and psychologically and how relevant it was as a descriptor in the support and care of individuals.  I was therefore delighted to read a piece in the last few weeks by the respected clinician David Oliver which confirmed both my own unease with the term and why it is important that we reconsider our views of frailty.

In that paper Oliver reminds us of the uncomfortable debate in spring 2020 in the midst of the first Covid wave, on the use of the Clinical Frailty Scale (CFS) as a tool ‘to triage, target, and potentially ration scarce intensive and high dependency care.’ With many others I was critical at the time of the use of such a tool as a proxy for individual and person-led clinical decisions and the dangers of age discrimination which might result.

It is important in any debate on frailty to recognise that it has positive dimensions to its usage. As Oliver states:

‘in over 75s registered with NHS practices, severe frailty as defined by an electronic frailty index is associated with far higher risk of hospital admission, death, or care home admission in the following 12 months. People with frailty have less functional reserve and are far more likely (with or without covid-19) to present with immobility, falls, confusion, or generalised failure to thrive, or to get stranded in hospital or experience acute loss of function. Those in care homes, or who have dementia or are receiving home care or post-acute rehabilitation, will often be frailer and older.’

As a general term, therefore, there are clear benefits in being able to use models which can be early predictors of the benefits of additional support and intervention. As a preventative assessment measure such frailty tools are invaluable in achieving both better outcomes for the individual person and in reducing the economic health costs for the rest of society brought about by unnecessary hospital admission.

But the term is not neutral and can be used sometimes with inconsistency and contradiction. Indeed frailty is a term and concept which as researchers like Archibald et al have shown is not widely understood by the general population and is negatively viewed as a descriptor by older people themselves. They argue in their research that the use of the term may actually serve to harm key public health messaging.

A critical dimension of the care and support of older people is to enable individuals to maximise independence either in their own home, in the community or in a care home. Most associations on frailty relate to a loss of independence predominantly due to challenges with mobility and a loss of control over one’s environment. Frailty clearly both at the popular level and clinically carries with it negative connotations.

There are a couple of points in this extensive debate which I want briefly to make in this blog.

The first is that at times there can be too great a stress upon frailty seen as physiological decline without a resultant emphasis upon psychological, emotional and environmental changes and challenges, and

Secondly, I wonder if it is time to collectively replace the concept of frailty with a more positive modelling based on how we should be enabled and assessed as ‘ageing well’?

Turning to the first issue. There is now a wide professional acceptance that frailty is not solely about physical decline, either of mobility or other functions. There is an appreciation that we need to have and adopt a holistic understanding of frailty. An individual’s circumstances and the constraints on their independence are a product of many factors, including their physical environment, their psychological well-being, the extent and degree of their relationships and social connection. Frailty therefore cannot simply be a score on a chart to take account of changes in someone’s physical health.

But when I speak to practitioners and to those older persons who access health and care services, such a holistic understanding of frailty seems frustratingly absent and missing. They complain about the dominant emphasis and focus on their physical health and a limited or absent appreciation of their psychological, social and relational well-being.

From my own experience I can remember my great aunt who was an astonishing woman still writing articles and letters when she was 94. She had a fall which resulted in a hip fracture and underwent very successful surgery. Her rehabilitation focussed on her physical return to health. The stress was upon addressing her frailty. But over a short period, she declined sharply, and it wasn’t the physiological decline – as I said surgery went well and she responded astonishingly well – but it was the impact psychologically that it had upon her and her confidence which those around her recognised as the major factor in her change. Yet nobody attended to that because all they could see was the physical decline and frailty and not the change in the person.

The person who has had a hip fracture at home because of isolation and loneliness and lack of social care support and ends up going into an acute hospital for a replacement – their intensive rehabilitation back in the community isn’t – should not be – simply about enabling them to get back on their feet, to mobilise, to be able to ‘look after themselves again’. If that is all we’re doing, we’re only attending to the physiological functional dis-ease. We’re not attending to that connectedness of the person who needs to be able to maintain relationship with neighbours and with their community, and nor are we attending to their mental health needs because that certainly, in my experience of frailty and falls, is what we often forget because we’re so focused on the physiological. We know about but often fail to respond to the sheer mental distress, trauma and psychological fatigue which occurs when somebody has a major fracture whether it happens in their 60s or in their 90s.

I think we are some considerable distance from a situation where there is a robust multi-disciplinary team awareness across health and social care of the multiple factors that contribute to the decline and change in the health story of an older individual.

Another really important recent study from Coker et al makes the same point of a gap between awareness of the need for a holistic understanding of frailty and what actually happens in practice. Summarising their research study, they state:

‘There was a shared narrative among participants that frailty is an umbrella term that encompasses interacting physical, mental health and psychological, social, environmental, and economic factors. However, various specialities emphasised the role of specific facets of the frailty umbrella. The assessment and management of frailty was said to require a holistic approach facilitated by interdisciplinary working. Participants voiced a need for interdisciplinary training on frailty, and frailty tools that facilitate peer-learning, a shared understanding of frailty, and consistent assessment of frailty within and across specialities.’

I could not agree more about the necessity to move beyond biomedical descriptions of frailty and to support older people in a more holistic manner utilising the professional skills of all social care and health care staff.

The second issue I raised above was the suggestion that perhaps we need to move beyond frailty descriptors and to develop a more positive modelling based on how we should be enabled and assessed as ‘ageing well’

The language we use in life and in our descriptions of how we value living are critical and there can be no doubt that concepts of frailty are negative, limiting and associated with decline and deterioration. Whilst ageing does indeed for all result in change and alteration and for some that includes elements of physical or psychological change, it does not always need to be perceived in a negative and diminishing manner. Why do we see such change as negative? Is it because our societal ideal is still a concept of humanity rooted in a cult of physical prowess, our vision of humanity one of the ‘whole and able’, and that inevitably ageing, and the change that accompanies it, is seen through a negative lens?

I think the continual impugning of negative association with frailty is preventing us from being positive about ageing. If frailty impacts almost inevitably for those who age then why should we see it as decline and deficit rather than as natural and normal, to be lived through rather than avoided?

As more and more of us live for longer and longer periods of time and increasingly with healthier older age, we really need to grow up in our attitudes about age and the extent to which we either on the one hand dismiss the benefits of older age or elevate them to a false authority. Neither is entirely accurate nor helpful.

Instead, we should, I would contend, be seeking to adopt a positive view of ageing and a model of care and support, both healthcare and social care support, which is oriented not on a negative paradigm such as frailty but on the positivity of ageing. This is after all the World Health Organisation’s Decade of Positive Ageing!

Frailty is the consequence of ageing for many of us and it will happen both physically and psychologically at different stages for different people. We have to own it and see it as one of the glorious realities of us all getting old which for many of our forebears was not a possibility.

Yet in descriptions of frailty and ageing the norm is on too many occasions a limited clinical view. This is the description of ageing I came across recently – it described it as  ‘characterised by a complex and intraindividual process associated with nine major cellular and molecular hallmarks, namely, genomic instability, telomere attrition, epigenetic alterations, a loss of proteostasis, deregulated nutrient sensing, mitochondrial dysfunction, cellular senescence, stem cell exhaustion.’ Dictionaries available online!

To age has to be seen as the flourishing of our lives, despite the challenge of the passing years. So, it is time both to broaden our vision of ageing well and to re-consider whether frailty as a concept should be replaced by ageing. Or perhaps weathering?

The late Whithorn born poet Alastair Reid sums the changes brought about by ageing in a manner that for me captures its essence – I would rather weather with the time of age than decline on a clinical frailty scale any day!


I am old enough now for a tree
once planted, knee high, to have grown to be
twenty times me,

and to have seen babies marry, and heroes grow deaf –
but that’s enough meaning-of-life.
It’s living through time we ought to be connoisseurs of.

From wearing a face all this time, I am made aware
of the maps faces are, of the inside wear and tear.
I take to faces that have come far.

In my father’s carved face, the bright eye
He sometimes would look out of, seeing a long way
through all the tree-rings of his history.

I am awed by how things weather: an oak mantel
in the house in Spain, fingered to a sheen,
the marks of hands leaned into the lintel,

the tokens in the drawer I sometimes touch –
a crystal lived-in on a trip, the watch
my father’s wrist wore to a thin gold sandwich.

It is an equilibrium
which breasts the cresting seasons but still stays calm
and keeps warm. It deserves a good name.

Weathering. Patina, gloss and whorl.
The trunk of the almond tree, gnarled but still fruitful.
Weathering is what I would like to do well.

Alastair Reid

from Weathering: Poems and Translations (New York: E.P. Dutton, 1978; Copyright © 1978 by Alastair Reid. All rights reserved)

Donald Macaskill


This blog will next appear on the 14th August.

Climate Action and the Social Care Collective

We are co-hosting a series of virtual roundtable events to explore climate change in the context of social care with The Health and Social Care Academy (an ALLIANCE programme). Discussions will consider both the impact on the sector and the action required to tackle climate change. 

In the run up to COP26, we will be holding a series of roundtable events which will foster dialogue and explore the crucial role that social care must play in the context of climate change – in addressing, adapting to and taking action to mitigate the impacts. 

Scottish Government has pledged to be a net-zero nation by 2045 and Industry and investments are going green. There is a need for the social care sector to be involved in supporting sustainability effort as it is both affected by and contributes to climate change. Presently, there is little policy and action being taken to deliver social care in a changing climate. Given the mixed economy of care provision in Scotland, the impact of climate change will need to be acted upon by a range of different bodies, including local authorities, health and social care partnerships and care providers. 

Events will look at the current context, the barriers to action and will help identify solutions that can be taken forward by the sector as a call to action. It is our hope that these roundtables start to foster innovation, inspire action in the sector and ensure that social care is recognised as an equal partner in tackling climate change. 

The series will inform a set of principles and a call to action to inform stakeholders and groups on the areas for constructive and collaborative improvement in climate change and social care, which will be shared prior to COP26 on November 1, 2021. 

These roundtables will be held online on the following dates: 

  • Wednesday 11th August, 10:00 to 12:00 
  • Wednesday 15th September, 10:00 to 12:00
  • Wednesday 20th October, 10:00 to 12:00 

Final details for each event, including confirmed speakers, will be announced over the coming weeks. 

The events will be held on Zoom and are not designed to elicit person information from participants. For more information, please read our respective Privacy Statements: 


 Scottish Care 

Please sign up through Eventbrite.  If you have any questions or would like to learn how to get involved, please email [email protected]

Save the date – Care Home Conference & Awards 2021


We are pleased to announce that our annual Care Home Conference and Awards will take place this year on Friday 19 November 2021. Please get this date in your diary and share with your colleagues.

We are anticipating these events to be live and in-person at the Hilton Hotel in Glasgow (1 William Street, G3 8HT). However, this may be subject to change due to Government COVID-19 restrictions/guidelines at the time of the event.

More details to follow.

2021 Care Home Awards now open for entries

We’re delighted to announce that the 2021 Care Home Awards are now open for entries! Scottish Care would like to invite you to enter your company, staff and residents for the Care Home Awards 2021.

Help us recognise the work of fantastic staff and providers whilst also giving positive visibility to this often neglected sector.

There are 13 award categories:

  • Ancillary & Support Staff Award
  • Nutrition & Eating Well Award
  • Meaningful Activity Award
  • Training, Learning & Staff Development Award
  • Emerging Talent Award
  • Outstanding Achievement Award
  • Management & Leadership Award
  • Palliative & End of Life Care Practise Award
  • Nurse of the Year Award
  • Carer of the Year Award
  • Specialist Service/ Unit of the Year Award
  • Care Home Service of the Year Award
  • Positive Impact Award

Find out more about the awards and submit your nomination here.

Award entries close on Friday 10 September 2021.

Launch of ‘Time for Change: Conceptualising a National Care Framework’ report

Today, Tuesday 13 July we are pleased to launch the ‘Time for Change: Conceptualising a National Care Framework‘ report, a follow-up to the release of ‘Coileanadh‘.

In June 2020, Scottish Care began the Collective Care Future programme, which involved a series of engagements with a diverse range of people with experience and expertise in the social care sector in Scotland. From these contributions, we launched Coileanadh’ – a future landscape for social care that articulated eight concepts and 39 actions for change, underpinned by three priority areas of focus relating to the ways in which practice-based change can be achieved, implemented and sustained to achieve a positive vision for the future of social care. 

The findings from ‘Coileanadh’ were compared against the recommendations of the Independent Review of Adult Social Care to explore the synergies and areas of opportunity that can help to overcome the implementation gap that currently exists in adult social care and articulate the key requirements in conceptualising ‘National Care Service,’ summarised in the ‘Time for Change’ report. In doing so, we aim to offer a more holistic perspective on what such a service might look like and the resulting implications for how work in this context could be taken forward.

The actions identified are both complementary and distinct to the recommendations of the Independent Review. The report aims to demonstrate the authentic value of the social care sector to wider society and the relational interdependence that social care has with health. A broader view of social care that considers and encompasses key concepts around positive ageing, a life course approach, and the language we use when talking about social care is critical in supporting mindset shifts and realistic perceptions. We propose that within these first 100 days of new parliament, the actions articulated in ‘Coilanadh’ are adopted as complementary to the recommendations of the Independent Review, and that our work is included as part of the consultation process that the Government will carry out. It is our hope that this work is the start of a national conversation on the future of adult social care in Scotland.

Launch of the Independent Sector Nursing Data Report 2021

Today, Tuesday June 29, 2021, the Independent Sector Nursing Data Report 2021 has been published.

The report is aptly titled ‘A Look to the Future – Achieving the Nursing Vision.’ It provides an updated view of nursing in care homes and in the independent social care sector in Scotland with a look to the future of nursing in the sector. This report is a follow-on to the Independent Sector Nursing Data 2018 report.

We wanted to gain an updated view of issues in social care nursing and issued a survey to members on topics where we are aware of areas of longstanding difficulty, such as recruitment, turnover and retention. We also asked about nurse agency use, learning and development, and the areas where we as an organisation might help promote further development, such as nursing access programmes and prescribing courses. All questions considered the context of the pandemic as this has had a considerable effect over the past year and a half.

Social care nursing requires distinct expertise; nurses fulfil a complex and multi-faceted role where they enable people with care and support needs -many of whom have multiple co-morbidities and complex health issues- to live positively in homely settings. They support individual health conditions and understand the impact this has on their social and community life. We wanted to ensure the report focuses on the importance and perception of this area of nursing, with mention of where we can make improvements, not least through how social care nursing is valued and how to continue to support students and colleagues in years to come. It is time that our social care workforce is provided with parity of pay, terms and conditions, and are seen with equal value to NHS colleagues to have sustainable and inclusive growth.

We hope this report paints a clearer picture and provides greater insight into the significant workforce challenges facing nurses in the independent social care sector, where data has previously been limited, and therefore support a wider range of stakeholders to better understand the criticality of the issues. Further, it can lead to collaborative working around some practical solutions to address the challenges experienced by providers as well as to the continued learning and development of the nursing and care workforce. As an organisation, we will continue to challenge how people view, value and use language around social care to shift mindsets and demonstrate the real importance the sector provides to society.

Care at Home & Housing Support Awards Winners

Congratulations to our 2021 Care at Home & Housing Support Awards winners!

Scottish Care’s annual Care at Home & Housing Support Awards was held on Friday 25 June 2021. The awards ceremony took place virtually, hosted by Dr Donald Macaskill and Michelle McManus.

Huge congratulations to all of our deserving finalists and winners, and thank you to all the Awards Sponsors.


Scottish Care launches new social care data report

Scottish Care, the representative body for Scotland’s independent social care services, is publishing a new report which shares their vision for social care data. This report will be launched on the final day (Thursday 17 June) of their virtual Care at Home and Housing Support Conference.

The conference, ‘Homecare Festival’ – is a three-day event that brings people together from across the care at home and housing support sector to share their experiences and plan for the future of home care.

The report titledSeeing the diamond in social care data brings together findings from a series of data forums hosted by Scottish Care and involved colleagues from across the social care sector, industry, academia and government.

Scotland is data-rich but intelligence poor, whilst fragmented data collection, standards and access in social care have made data hard to navigate. The report highlights the importance of a human rights-based perspective, enabling people to have control over their data and how it is shared to initiate care and support on their own terms. Scottish Care seeks a vision where data is person-led; is based on the needs, wishes and aspirations of people for their care and support, informs the design of services and planning and the resulting indicators of performance and success.

Karen Hedge, National Director of Scottish Care commented:

“For too long, the fragments of social care data have been drivers acting on behalf of the social care system rather than on behalf of those who access social care and support. Implementing the principles and vision contained within this report, would completely turn that on its head and put the individual in control. In addressing the fragmentation, it also allows for better use of resources by enabling better coordination for planning and delivery.”

Launch of ‘Coileanadh’ – Manifesting a flourishing social care future for Scotland. 

 Today, Monday May 17, 2021, we are delighted to launchCoileanadh’ – the output of phase two of our Collective Care Future programme. We are delighted to launch the findings of this programme, articulated in a future change landscape created in collaboration with Andthen, a design strategy studio. The visual landscape embodies the contributions of a diverse range of expertise and experiences from providers, staff, people supported, families and wider partners in care and support in Scotland. The findings include eight concepts and three priority areas of focus relating to the overarching philosophy and culture, the policy and partnership enablers, and the way in which change can be enacted in social care practice.  

We invite you to explore the future change landscape, concepts and the actions for change identified and join us for the webinar launch on Thursday May 20th 2pm where we will share the findings and outline how we plan to continue the conversation around a National Care Framework.   

Building our collective care future’ is a collaborative programme which commenced in June 2020 with the intention of capturing the experiences of social care during COVID-19 to build on this learning towards developing a positive vision for the future social care. 

The insights and expertise shared from our engagements have been translated to inform actions that can allow decision-making and change to materialise, which will be invaluable to key stakeholders at local and national levels. The 39 actions roadmap the ways in which practice-based change can be achieved, implemented and sustained, resulting in a more equal, rights-based and wellbeing focussed society.  

We believe the actions identified are both complementary and distinct to the recommendations of the Independent Review of Adult Social Care. Coileanadh’ explores the synergies and areas of opportunity that can help to overcome the implementation gap and articulate the key requirements of a National Care Service, what we refer to as a National Care Framework. In doing so, we aim to offer a more holistic perspective on the creation of a National Care Framework and the resulting implications for how work in this context could be taken forward. The relationship and interdependence of social care and health highlights the need for a broader view that encompasses different ways to how we approach care and support across the life course and we hope that this work is the start of a national conversation on the future of adult social care in Scotland. 

If you would like to share any feedback on the findings or ways in which you can contribute to the actions identified, please contact: [email protected] 

Sincere thanks to all our participants, Scottish Care members and colleagues who contributed their expertise and experiences across the ‘Care Futures’ programme. 

 Details to register to attend the Coileanadhwebinar: 

Thursday 20th May, 2:00PM 

Registration link: 

 Webinar ID: 844 4924 6803 

Launch materials 

Full document: