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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Donald Macaskill

Photo by Shane Rounce on Unsplash

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

‘Keeping Orchids’

The orchids my mother gave me when we first met

are still alive, twelve days later. Although

 

some of the buds remain closed as secrets.

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

 

from her train station to mine, then home. Twice

since then the whole glass carafe has crashed

 

falling over, unprovoked, soaking my chest of drawers.

All the broken waters. I have rearranged

 

the upset orchids with troubled hands. Even after

that the closed ones did not open out. The skin

 

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

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

 

Her voice is fading fast. Even her voice rushes

through a tunnel the other way from home.

 

I close my eyes and try to remember exactly:

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

 

A digital watch her daughter was wearing when she died.

Now they hang their heads,

 

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

her hands, awkward and hard to hold

 

fold and unfold a green carrier bag as she tells

the story of her life. Compressed. Airtight.

 

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

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

 

A door opens and closes. Time is outside waiting.

I catch the draught in my winter room.

 

Airlocks keep the cold air out.

Boiling water makes flowers live longer. So does

 

cutting the stems with a sharp knife.

 

Keeping Orchids by Jackie Kay – Scottish Poetry Library

Photo by Kyla Flanagan on Unsplash

Donald Macaskill

 

The following extended blog was the substance of an address given at the second Social Care Nursing Conference, held in Edinburgh on the 4^th September.

At various points today and in a lot of conversation and chat we have used the phrase ‘social care nursing.’

It is one which I first came across when Scottish Care undertook research which became when it was published, the ‘Voice from the Nursing Frontline‘ all the way back in 2017. That was the first major piece of work undertaken in Scotland to actually discover the thoughts of and issues of importance to nurses who worked in a social care setting, predominantly care homes.

But the nature and distinctive role of social care nursing is often misunderstood, sometimes undervalued, but I would argue undeniably essential.

Indeed, at a recent nursing meeting some colleagues pondered about where the phrase came from and what it meant. Why is it, for instance, that our neighbours in England have for some time an appointee who is Chief Social Care Nurse?

So, with your permission I want to briefly reflect on why I believe it is important that we use the term and more especially why we need to stoutly advocate for social care nursing.

Put simply I would contend that

“Social care nursing refers to the provision of nursing care within social care settings, primarily focusing on the holistic needs of individuals in residential or community environments.”

It involves working with people who for one reason or another are both clinically and societally vulnerable and in need of support and care, such as the elderly, those with disabilities, and individuals requiring long-term care.

Social care nurses integrate core nursing skills with an understanding of social care systems, often collaborating with other professionals to support individuals in their daily lives.

The term “social care nursing” began to gain recognition in the UK around the early 2000s. The specific term “social care nursing” is difficult to trace to a single, definitive point of origin. It emerged as the boundaries between health and social care became more integrated, particularly with the increasing emphasis on person-centred care and the growing demand for nursing expertise within social care settings. This development was part of broader health and social care reforms aimed at improving care delivery and outcomes for individuals requiring long-term support.

What is Social Care Nursing?

Social care nursing is distinctive because it blends clinical nursing skills with an emphasis on social care, focusing on the broader, long-term needs of individuals in community or residential settings. Unlike other nursing disciplines which might prioritise acute care in hospitals, social care nursing is centred on supporting people in their daily lives, often addressing chronic conditions, disabilities, and the complexities of aging. It requires a deep understanding of social care systems, person-led care approaches, and often involves working collaboratively with multidisciplinary teams to enhance overall well-being and independence.

The social aspect of social care nursing is critical and distinctive – it is the delivery of nursing care and support not just to an individual within a community environment, but to the community of persons within a social care setting. The collective, communal, relational dimension is key to the distinctive and uniqueness of such nursing. This is not just nursing to maintain individual health and wellbeing, but that of the wider network of relationships and community.

I am not saying that acute or indeed community nursing does not focus on the personal or is not person-led, but there is something very different about delivering nursing and clinical care within a social care setting.

Some may ask – is this not just nursing? Ordinary nursing? Well on one level yes, but on another level, it is important to recognise the distinctive aspects of different disciplines within nursing. To celebrate those differences within the one family, in order to grant to that distinctive strand a sense of value, autonomy and respect is I think critical for that discipline to have a sense of identity and to better understand its contribution to the field of nursing.

I would not say to a learning disability, a paediatric or an intensive care nurse that there was nothing ‘special’, distinctive or unique about their role. That would be to undermine their specialist knowledge, skill, aptitude and contribution to a clinical or care team.

Alas I have heard too often the phrase or equivalent that ‘you are just a care home nurse’ or that there is nothing ‘special’ about being a nurse in a care home or social care setting. Even worse that it is an ‘easier’ form, of nursing. And I do sometimes wonder if the resistance amongst some, including those in nursing education, to the specialisms around aged care, dementia, late-stage neurological conditions etc, has more to do with systemic and societal ageism and discrimination than anything else.

Social care nursing is different. It is special. It needs to be celebrated and recognised for its own distinctive contribution. But when I articulate as I will briefly why it is important and distinctive that is NOT me seeking to demean other forms of nursing.

Essential elements.

At its core, social care nursing is about holistic care. It is about providing care that is as much emotional and psychological as it is physical. It is about supporting people in their own homes, in care homes, or in their communities. It is about understanding the diverse needs of older people, people with disabilities, those with mental health challenges, and those who are living with long-term conditions. It is about helping people to live their best lives, no matter their circumstances. In that sense it is inherently social care which is about enabling the fulness of individual life and contribution.

Social care nursing is not confined by walls. It is not limited to the sterile environment of a hospital ward or the controlled setting of a clinic. Social care nurses work in the real world, in the places where people live their lives. So too do our colleagues in community nursing but the distinctiveness again is that these are nurses who work in specific social care settings. Which are not just buildings but communities of inter-relationships.

They work in care homes that become real homes. They work in a way that seeks to ensure that care must be personalised, sensitive, and respectful of privacy and dignity.

Social care nursing is vital because it meets people where they are. It supports those who are often the most vulnerable, the most marginalised, and the most in need of compassionate, human-centred care. While other types of nursing are undoubtedly critical — whether it is in surgery, in A and E, or in acute care — social care nursing stands apart because it focuses on living, not just surviving. Its focus is on how someone can achieve their potential (not just be maintained and clinically well.)

It is important because social care nurses do not just care for people; they care about people. They do not just address symptoms; they address the whole person. They help individuals manage the complexities of daily life, maintain independence, and achieve their own unique aspirations. They are the link between health and social care, bridging the gap and making the transition from one to the other seamless and person-led.

What unites many of these characteristics is that social care nursing is fundamentally about the development, nurturing and maintaining of long-term relationships. Such relational care is not always possible in other settings, but a social care nurse is (or at least should be) gifted with the ability to enable someone to tell their story, to build a relationship with someone so that trust and openness and confidence can be formed. The practitioner becomes part of the person (and their family’s) story.

But let us be clear — I really do believe that the importance of social care nursing goes beyond the care provided to individuals. Social care nursing is also about shaping communities. It is about advocating for the rights of those we serve, about speaking up for those who cannot speak for themselves, and about ensuring that everyone — regardless of age, ability, or circumstance — has the opportunity to live with dignity and respect.

Therefore, social care nurses are champions of social justice. They challenge inequality and injustice wherever they find it. They do not accept that someone should receive less care because they are older or less attention because they live in a rural community. They believe in fairness, in equality, and in the fundamental human right to care and support.

Social care nurses are innovators. They are creative, adaptive, and resourceful. They are constantly finding new ways to deliver care in challenging environments, to meet needs with limited resources, and to bring about positive change in their communities. Partly this is because of the highly autonomous way in which they work, but if you want a problem solved get a social care nurse!

Why We Must Value Social Care Nursing

So, let us recognise the unique role that social care nurses play. Let us value their work, their dedication, and their compassion. Let us understand that social care nursing is not secondary to any other form of nursing; it is essential. It is essential to the individuals we care for, to the communities we serve, and to the society we seek to build — one that values every person, cherishes every life, and upholds the dignity of all.

Social care nursing is about the moments that matter — the moments of joy, of connection, of comfort, of companionship. It is about being present in someone’s darkest hour, about celebrating their smallest victories, and about ensuring that, whatever their journey, they do not walk it alone.

So today, I hope we can all celebrate social care nursing; recognise its importance, advocate for its value, and ensure that it receives the recognition, the respect, and the support it deserves.

Because when we champion social care nursing, we champion nursing.

Donald Macaskill

Photo by Clark Tibbs on Unsplash