There are a lot of journalists in my extended family and indeed journalism and writing has always been very important within the wider family. At one time as much younger person I even toyed with the idea of becoming a journalist influenced as I was by the heroic endeavours of the Washington Post writers Carl Bernstein and Bob Woodward who exposed the scandal of Watergate and played a massive part in the downfall of Nixon.

More recently in my professional life I have had more than most people’s experience of dealing with both print and other media journalists – and by in large it has been a positive experience – because I have found them to be individuals whose primary focus was to enable you to tell your story and if investigation was required for a piece they did so with an approach which was as respectful as possible.

I’ve found myself thinking about journalism as today is World Press Freedom Day or simply World Press Day – as it is each year on the 3rd of May. It is a moment to reflect on the importance of a free and independent press, the courage of journalists who speak truth to power, and the role of media in holding society to account.

Sadly, as too many know there are parts of the world where the freedom to speak truth to power is one that costs the lives of too many journalists. In 2024, a record number of journalists and media workers lost their lives while performing their duties. According to the Committee to Protect Journalists (CPJ), at least 124 journalists were killed globally, marking the deadliest year since the organisation began tracking such data over three decades ago.

World Press Day for me is also a moment to ask – whose voices do we not hear? Whose truths remain unspoken? Whose story is rarely told in both printed and visual media?

In the world of social care, we work every day with those whose stories too often remain hidden behind doors marked “vulnerable,” “elderly,” or “complex needs.” We serve people whose words may be soft and quiet or whose communication may not come in familiar forms. People whose voices, whether through age, illness, disability, or marginalisation, are too easily ignored in the national conversation.

In Scotland, as I have stated often – we pride ourselves on being a nation of compassion and community. But compassion must include the act of listening – really listening – to those on the margins. A truly free society is not only one where the press can publish without fear, but one where all voices are amplified, especially those who experience silence imposed not by censorship or deliberate design, but by neglect and invisibility.

I think of the individuals I’ve met in care homes who have led rich lives – teachers, poets, nurses, labourers – now facing the end of life almost unnoticed and some with so much to say but no one interested in listening. I think of the incredible care staff, often undervalued and overworked, whose experiences should shape public policy, yet they rarely find space in national debate. I think of unpaid carers who give their days and dreams to support those they love, rarely asked for their opinion by decision-makers.

Right across social care services there are stories that rarely see the light. Stories of resilience, of love and heartbreak, of injustice and of quiet triumph. Stories that tell us more about the soul of our society than any press release or political speech.

But these stories are not often told – because the individuals who live them are too often viewed as recipients of care, not as narrators of their own lives.

At the same time the media narrative about social care remains stubbornly stuck in crisis. And I must confess I probably in part have been responsible for contributing to those column inches.

Social care appears in the news when things go wrong. When budgets are slashed. When someone dies. When a ‘scandal’ breaks. Rarely are we told of the joy in care homes, of the laughter when someone is supported in their own home, of the small, sacred moments of connection between carer and supported person. They are not ‘news’ – they are the ordinariness of relationship as being in community.

I think we need a new kind of press freedom – one that seeks out not just political controversy, but human truth.

We need journalists who will sit beside someone who uses social care and ask not what’s broken, but what matters to you?

We need editors who will give column inches to care workers, who will treat the voices of people who use services with the same weight they give to ministers and CEOs.

We need a Scotland where the press plays its part in ensuring that care is not only reported but understood.

Because in a truly free society, everyone’s story matters.

So, on this World Press Freedom Day, I certainly want to fight for the protection of journalists around the world but also want to shout out for the amplification of those whose stories go untold.

The freedom of the press is not simply the right to publish. It is the duty to listen.

And if we are brave enough to listen to the voices in social care, we might just learn something profound about who we are, and who we could become as individuals and as a society.

I leave you with some of the words of an American poet Patricia A Fleming. Raised in Trenton, New Jersey, she pursued a career as a psychiatric social worker, dedicating 36 years to supporting individuals facing mental health challenges. Upon retiring in 2016, Fleming rekindled her passion for writing, channelling her life experiences into poetry that offers inspiration and solace to readers. She has argued that it is critical that those on the margins must be given opportunities to tell their story and know that it is seen and being listened to. In December 2023, Fleming published her first poetry collection titled Being Human In This Crazy World.

The following poem encapsulates the power of storytelling, especially in the context of personal experience and resilience,

The Legacy of My Words

By Patricia A. Fleming

 

My words are like my heartbeat.

They tell the world that I’m alive.

They recite the tale of who I am

And of all I have survived.

 

My words reveal my deepest pain.

They betray my greatest fears.

They share moments of my laughter,

As well as moments filled with tears.

 

They are the legacy I leave behind

When my time on earth is through.

They’ll offer others hope and strength

To help them make it too.

 

So I’ll write my words with courage,

And I’ll speak them loud and clear,

For in the telling of my story,

I find my purpose here.

 

https://www.familyfriendpoems.com/poem/the-legacy-of-my-words

Donald Macaskill

 

“It is more than just a jag for some of us it has meant a new lease of life.”

Those were comments which I heard many years ago from someone who every year had been faced with debilitating respiratory conditions and for whom vaccinations had made a huge difference to their quality of life.

They came to mind to me recently when I read on the BBC a story which showed that there had been a massive increase in deaths this past winter as a result of the flu. National Records of Scotland data for the first 14 weeks of this year showed that the flu was the underlying cause in 463 deaths. In the same period last year there were 240. As well as these an additional 567 recorded deaths have had flu mentioned on the death certificate so far in 2025.

These are huge numbers but more than that these are lives of people of all ages some of which could have been prevented had individuals only been vaccinated. Campaign groups like Asthma and Lung Scotland argued that a decision to raise vaccination eligibility to 65 meant an additional half a million people were not offered the jab this winter. Flu deaths are at the highest number since 1979.

Information from Public Health Scotland shows overall flu vaccinations this winter are down by a fifth compared to the previous winter, with over 350,000 fewer vaccines administered. In 2023/24, almost 1.65m people received a flu vaccine, with numbers falling to under 1.3m in winter 2024/25.

This strikes me as a worrying and concerning trend which clearly needs to be addressed as a matter of urgency.

World Immunisation Week runs from the 24^th to the 30^th April. Run under the auspices of the World Health Organisation (WHO) it aims to highlight the collective action needed to promote the use of vaccines to protect people of all ages against disease. ‘The ultimate goal of World Immunization Week is for more people – and their communities – to be protected from vaccine-preventable diseases.’

There is something profoundly symbolic about a vaccine. A tiny vial. A momentary pain. And yet it speaks volumes – of science, of solidarity, of hope. This World Immunisation Week, I want to focus not just on the immunological mechanics of vaccination, but on what I personally consider to be the moral imperative it carries, especially for those who are older in our communities.

The low and declining levels of vaccine uptake are and should be a considerable matter of societal and public health concern, not least for our older population.

We have come through years in which misinformation has taken root like an invasive weed within our public discourse. Anti-vaccination sentiment has not only reared its head in dark corners of the internet and social media platforms, but it has been given a voice, if not a megaphone – even in positions of power.

The recent data which has revealed a concerning increase in deaths linked to seasonal flu are not just numbers. These are lives. Mothers, fathers, carers, grandparents. People who contributed to the common good for decades. People who have earned the right to live with dignity and with every protection that our modern world can offer.

I am increasingly concerned that despite the fact that we have the vaccines, that we have the expertise to prevent more deaths through targeted immunisation programmes that we seem to lack a clinical and political priority, and to lack, at times, the collective will to address what feels like a failure.

Let’s be clear: vaccines save lives. The data is irrefutable. Vaccination against flu, COVID-19, shingles, and pneumococcal disease drastically reduces hospital admissions, long-term complications, and yes, death. But even more than that – it protects the experience of ageing. It protects community, continuity, and connection. It protects stories, memories, and wisdom that we so often say we value – and then forget to act to preserve.

When we allow anti-vaccination rhetoric to go unchallenged – whether it comes from TikTok pseudoscience or from high-ranking officials – we risk turning a blind eye to preventable harm. We risk undermining one of the most successful public health interventions in human history. We risk failing those who trusted us to care.

This World Immunisation Week it is a matter of urgency and priority that every policymaker, every care professional, every family member: reclaim the societal narrative. Let’s drown out the noise with compassion and facts. Let’s centre older people in our public health planning – not as afterthoughts, but as equal citizens whose protection matters.

I am increasingly of the view that we need a campaign in Scotland that is bold, inclusive, and deeply human. One that does not patronise but empowers. One that is shaped by the voices of older people themselves, by care workers on the front line, and by community leaders. A campaign that does not whisper but shouts: Vaccination is protection. Vaccination is solidarity. Vaccination is love in action.

Too often in the last couple of years in particular we have whispered the benefits of vaccination and have reduced the fiscal spend on advertising and promotion. Too often I hear the phrase ‘vaccine fatigue’ without the counter argument that you address fatigue not by walking away but by enabling concerns to be addressed and improving access and accessibility. I am not at all convinced that we have made it easier to access vaccines – in fact I think we have made it harder. If I am honest the world of winter vaccines now is massively complicated whether it is for Covid or for flu. See a recent BBC information site as an example of this complexity.

The Scottish Government minister Maree Todd is recently quoted on the BBC as stating that:

‘ “vaccine fatigue” and “anti-vax sentiment” may also have played a part in reduced vaccine uptake.

The minister said there was high uptake from children and those at high risk, but there was “poor uptake from adults right across the board”.

She said the government would “certainly reflect” in the coming months on the decision to exclude the 50 to 64 age group.

“The JCVI look very carefully at the evidence and made the recommendations according to the clinical evidence,” she added.

“I think its very wise for governments to pay attention to the experts in this area and absolutely we listen very carefully to the recommendations that the JCVI gives us and follow them.” ‘

Inevitably as with any public health intervention there is a cost/benefit analysis. We have, I feel, to argue within the wider public arena that such assessments cannot solely be based on clinical benefit alone, but upon wider sociological and communitarian grounds, and in addressing systemic and subtle discriminatory practice.

Vaccines are not just a health tool. They are a human right. Let’s honour that -together. We cannot afford another winter where deaths from flu increase unnecessarily. We must protect those we can regardless of circumstance or age. That requires consistent and coordinated effort and World Immunisation Week strikes me as a good time to start.

Donald Macaskill

Photo by John Cameron on Unsplash

Well, here we are at the Easter weekend – and on that intriguing day of Easter Saturday – lying as it does between pain and promise.

Recently I’ve been doing a considerable amount of media and commentary trying to draw attention to what I consider to be the critical and perilous state of social care across Scotland.

Several of the articles and journalists have remarked upon and have indeed used the phrase that I have shown increased ‘anger’ at what is happening. Indeed, one colleague joked recently with me that I seem to be becoming much ‘angrier in my older age’. It’s made me reflect on the nature of anger and whether showing emotions of that kind are appropriate or not.

In truth there are days when frustration becomes too familiar. Days when the words spoken about social care in Scotland sound like echoes from decades ago. Strategies are launched, promises made, consultations held – and yet the needle barely moves. People wait. Carers bend under the weight of fatigue. The system holds – just – but creaks at every joint. And all the while, we wrap it in bureaucratic language and call it “complex.” But complexity should never be an excuse for injustice.

And then someone tells me to calm down. To be reasonable – not to get carried away and constantly criticise. To be patient. To wait for reform and change and new direction.

No.

There is a time for calm. But there is also a time for fire. And yes, I think and feel ever more that there has to be a time for anger.

We don’t speak enough about anger in public life – certainly not the good kind. But maybe we should. Because there is, I believe, a positive role for anger in the Scotland we are trying to shape.

I’m not talking about fury that burns everything in its path. Not the destructive kind that wounds and withers. Not the rage that lashes out in bitterness. But the righteous anger – the kind born not of ego or outrage for its own sake, but of love. Love for people who are being left behind. Love for a vision of care that is compassionate, dignified, and real – and not forever deferred to the next Parliament, the next review, the next economic upturn. The anger that refuses to accept what is as all that will be.

This is not a policy point. It is a moral one.

We grow used to the statistics, the delayed reforms, the “next budget,” the whispered apologies from policymakers that “now is not the time.” And yet – in the quiet of this Easter Saturday – I feel the growing heat of a deep, simmering anger. Because the way we treat social care in this country is nothing short of collective societal abuse.

And when all’s said and done, I suspect that there is something profoundly Scottish about a people who will not stay silent in the face of injustice – who keep going back to the doors of power, not with shouts alone, but with stories, tears, spreadsheets, and quiet fury. That kind of anger doesn’t destroy. It builds. It unearths. It refuses to let a broken system bury the truth.

I’ve just spent a few days back ‘home’ on the island of Skye and have walked some of the places, visited some of the ruined villages and empty glens where people refused simply to back down, to be silent, to go along with what was happening. Maybe it’s the oxygen of that renewal that makes me in my own ‘settled’ life angry at the intransigence, the waste, the lost opportunity, the missed connection, that so many people are having to endure by the absence of social care.

And here is the truth: social care in Scotland is not broken because we lack evidence or expertise. It is broken because we have not yet decided, as a country, that care matters enough to act. That it is not a burden but a foundation. That it is not an afterthought but a starting point.

Public opinion matters. But public opinion only shifts when it is unsettled. When it is stirred. When it is forced to confront what it would rather ignore.

And anger – held well, spoken wisely – can be the match that lights that shift.

We have seen flashes of it: in care workers refusing to be treated as second-class citizens; in families fighting for support that should be their right, not their reward; in campaigners who turn grief into grit.

That anger is not dangerous. It is necessary.

It is the anger that refuses to accept the underfunding of human dignity.

It is the anger that sees the gap between rhetoric and reality – and calls it out.

It is the anger that remembers the names of those who died waiting

We are not asking for charity. We are demanding justice.

So let us not apologise for our fire. Let us tend it. Let us use it to forge something better. Because if we are to move public opinion, we must first speak with the voice of conviction – not as technicians of reform, but as citizens who care too much to stay quiet.

Anger, rightly held, is the voice of conscience.

And right now, Scotland needs to listen.

This Easter weekend I leave you with the words of the late American poet Adrienne Rich and her poem What Kind of Times Are These

 

‘There’s a place between two stands of trees where the grass grows uphill

and the old revolutionary road breaks off into shadows

near a meeting-house abandoned by the persecuted

who disappeared into those shadows.

 

I’ve walked there picking mushrooms at the edge of dread, but don’t be fooled

this isn’t a Russian poem, this is not somewhere else but here,

our country moving closer to its own truth and dread,

its own ways of making people disappear.

 

I won’t tell you where the place is, the dark mesh of the woods

meeting the unmarked strip of light—

ghost-ridden crossroads, leafmold paradise:

I know already who wants to buy it, sell it, make it disappear.

 

And I won’t tell you where it is, so why do I tell you

anything? Because you still listen, because in times like these

to have you listen at all, it’s necessary

to talk about trees.’

https://www.poetryfoundation.org/poems/51092/what-kind-of-times-are-these

Photo by ran liwen on Unsplash

Donald Macaskill

As regular readers of this blog will know there are very few occasions when I get the opportunity to be celebratory or even positive these days given the state of things! So, I hope you will excuse the moment of positivity when I highlight that nine days ago (3^rd April) in Geneva, we witnessed a step which many of us thought would never arrive – the United Nations at a meeting of its Human Rights Council voted (by consensus) to begin the process of drafting a new Convention on the Rights of Older Persons.

Some of you might recall that nearly a year ago I had the honour of speaking at the UN session in New York when a vote was taken to take matters to the next step – finally (and nothing happens fast in international diplomacy) we are there! For years – decades, in truth – advocates, campaigners, and older people themselves have called for a binding international instrument that affirms, protects and promotes the human rights of older persons. At last, the voices of those too often consigned to the margins are being centred in a process that could shape global and local policy for generations.

I’ve long argued that the way we treat our elders is the clearest mirror of our moral character as a society. In Scotland, we like to think of ourselves as progressive, fair-minded, and caring. And in many ways, we are. But even here, we cannot escape the creeping ageism that lingers in our systems and structures – the subtle assumptions that older people are passive recipients of care rather than active agents of change; the failure to adequately fund social care; the absence of older voices in decisions that affect their lives.

Some have argued to me that there are enough legal protections and safeguards for our older citizens and that we have protections on gender, on race, on disability etc that cover age. Yes, it is true there are protections, but I earnestly believe that there are gaps in the law which make it possible and perhaps even inevitable that peoples and societies have and will continue to treat older people less favourably and with negative discrimination simply because they are old, and because of the acceptability of ageism tied to a negativity around growing old. So, for those reasons alone we need international and national law to be more robust around older age.

I was reminded of this urgent need when I read a report which came out from Independent Age when the same week as the UN vote they published the first Older People’s Economic Wellbeing Index for Scotland 2024-25.

This is the first edition in an annual series of nationally representative polling designed to deliver further understanding of the financial wellbeing and lives of people in Scotland who are of State Pension age. The results are as they stated ‘concerning, demonstrating the scale of the income, costs and housing pressures faced by older people living in financial hardship, and the actions they are taking when faced with squeezed finances.’ In summary it showed that:

• One in five (19%) older people in Scotland have a household income of under £15,000 a year.
• One in five (21%) older people in Scotland say the State Pension is enough to cover basic living expenses.
• Almost one in three (29%) older people in Scotland have skipped meals in the last 12 months.

‘Some groups are disproportionately impacted – with women, people with caring responsibilities, and people who live with a health condition more likely to have cut back on essentials, have a lower income or more difficulty affording housing costs.

The issue of rising pensioner poverty goes to the heart of the criticality of human rights and the need for governments at national and local levels to take action to protect the rights of older persons and to take measures and mitigations to ensure that these rights are not further eroded and removed.

This report and so much of my own day to day experience of speaking with those who receive care and support in Scotland, who feel that they are treated less favourably because of their age or are limited in career or life opportunity because of age – belies the myth that we protect the rights of older people in Scotland. The first step towards any new Convention has to be the acceptance of the rampant currency and extent of age discrimination in Scotland.  But more positively, what might this UN Convention mean for Scotland? Allow me to dream after a week of spring sunshine!

Firstly, the creation of the Convention has the potential to be a call to action. It is an invitation to reimagine how we see ageing – not as decline, but as a continuing expression of citizenship and contribution. It is a chance to embed into law the principles we espouse in policy: dignity, participation, equality, and independence.

A Convention is not just words on paper – it is a statement of intent. It shapes expectations, guides funding, informs law, and holds governments to account.

But it must be bold. It must be brave. And it must be grounded in the lived realities of older people.

Here are eight of my asks.

1. A Right to dignity in ageing

Not as a nicety, but as a fundamental entitlement. This includes access to high-quality care and support, to autonomy and choice, and to a life free from neglect, abuse and discrimination.

2. A Right to participate

Older persons must not be excluded from political, cultural and social life. Their voices should be at the table – from community decisions to national policy, from the boardroom to the ballot box.

3. A Right to health and wellbeing

Comprehensive, holistic, age-appropriate health and social care services must be guaranteed, including mental health support, palliative care, and rehabilitation.

4. A Right to lifelong learning and employment

The Convention must challenge the arbitrary cut-off points that deny older people the chance to work, learn, volunteer, or contribute. Age must not be a barrier to opportunity. We must tackle and penalise those who use the workplace to discriminate.

5. A Right to protection from ageism

Explicit recognition of ageism as a form of discrimination is essential. We must name it to challenge it. The Convention should enshrine protections in law and promote public awareness campaigns across Scotland and the globe.

6. A Right to adequate income and social protection

Older persons must be protected from poverty through fair pensions and access to benefits. No one should grow old in fear of being forgotten or impoverished.

7. A Right to home and community

The ability to remain in one’s community, in accessible and safe housing, must be guaranteed. This includes access to digital infrastructure and transport.

8. A Right to digital and technological inclusion.

In the rapidly changing world of technology and data it is critical that older persons are able to exercise their full rights of inclusion, participation and empowerment to control rather than be controlled by technologies.

Scotland has an opportunity – actually if truth be told a responsibility – to lead in this space. We already talk of a human rights-based approach to social care, of embedding PANEL and FAIR principles, of shifting from transaction to transformation. But these aspirations must now find foundation in international law and local practice.

But heaven forfend we wait another decade for pen to touch paper – we cannot and should not wait for the ink to dry on the Convention. We should begin living its principles now.

So, let’s dream truth into action and let our nation and communities be known not just as a place where people live longer – but where people live better, with rights respected and voices heard, from the first day to the last.

Donald Macaskill

It’s been a funny old week of oscillating emotions from a day in which I spent talking about how social care has the potential to be the economic driver of our communities to the next day when I gave a speech bemoaning the fact that the social care sector was being treated like April Fools because of the gap between political rhetoric which values social care on the one hand and the palpable reality of lack of priority and investment on the other hand.

But it’s also been a week where there have been moments of inspiration – when I’ve heard of colleagues in different worlds – for instance in the clinical and acute context – share insight and challenge around different and inclusive ways of doing things – ways which treat all with respect and which are grounded in the understanding that whether in social care or health we are all linked.

And so I find myself as we move towards World Health Day and Week reflecting in this blog on what I consider to be the real promise of a whole system approach to health and social care. A promise we talk a lot about not least in Scotland but have done so little to progress.

The first mark of that promise is that it starts with a holistic understanding of health. I know after all that in the end of the day and in all the conversations, committees, consultations and discussions I am involved in – that the majority of people across Scotland are not interested in whether you come from the world of clinical health or social care – they are interested in what difference will you make to their life when they or those they love most need support and care.

A holistic understanding of health is not reduced to clinical technical input but is so much broader and dynamic. That’s why I’ve always considered the definition of health which first appeared in 1948 from the World Health Organisation to be so appealing. It stated that:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

It offered for the first time a really multidimensional view of health. But some argued that it was both too idealistic for instance a question as to whether ‘complete well-being’ was ever achievable, whilst others stated at the same time that it was too narrow and limited. So, there are more contemporary and I think holistic interpretations which I like. The one that I use most first appeared over a decade ago in the BMJ – from Huber et al:

“Health is the ability to adapt and self-manage in the face of social, physical, and emotional challenges.”

Huber et al., “How should we define health?” BMJ, 2011

That definition has I think a sense of dynamic rather than being too static. Health is not a fixed state. It is always changing. There is a focus on the person and the individual and what it takes to live well not just to meet clinical outcomes. It recognises the profundity of relationships, and the conditions we live in – and I think it is holistic in that it encompasses physical, mental, emotional, spiritual and social dimensions of well-being.

So, if that’s our starting point – the promise of a holistic grounding and understanding of health, how do the systems of clinical, acute, secondary, primary, community and social care fit into this world and how do they collectively achieve this holistic vision?

Every so often, our national imagination is stirred by talk of reforming the NHS – and we’ve seen a lot of this in the media this last week – including a new operational framework and improvement plan – and undoubtedly it will become one of the go-to themes for the election next year. We will see conferences brim with vision, thought pieces and official papers will flutter with ideas and new possibilities. Political manifestos will beat with the drum of change, however unfunded and impractical.

But every time we talk about the health of our NHS, I find myself wondering – how can you heal one part of the body while ignoring the whole ? How can you address the challenges and reap the potential of the NHS without addressing and understanding the critical role of social care?

If you stand in a care home at 7am, you’ll see care workers gently waking someone who has perhaps not spoken since Tuesday. You’ll watch someone support a man to eat who is still fighting battles he long ago forgot. If you wait long enough, you might see someone cry – not because they are sad, but because someone has finally listened to them and heard their voice. That’s health. That’s care. That’s the invisible scaffolding that holds up not only the NHS, but communities themselves.

So when we speak of reforming the NHS in Scotland, we must be honest: no amount of reorganisation, digital dashboards or apps or indeed workforce and retention tweaks, no amount of increased salaries or improved terms and conditions, will ever succeed unless we grasp the fragile threads tying it to a social care system that is unravelling.

We have, I think for too long, clung to the idea that health and social care are separate domains. Hospitals for the sick. Care homes and homecare services for the frail. GPs for diagnosis. Social workers for discharge plans. This binary thinking – and believe you me it exists in abundance even if it strikes you as overly simplistic – has created a system where people fall between the cracks – cracks that grow into canyons.

A hospital bed can be cleared by a scan and a prescription. But where does that person go next? Who helps them eat, wash, recover? Who sits with them when night falls and confusion sets in? That’s not medicine. That’s social care and compassionate response. And without it, the hospital door becomes a revolving one.

So we need not just to talk whole system approaches but to walk it.

We’ve tried integration in Scotland. On paper, at least. Integration Joint Boards (IJBs), Health and Social Care Partnerships (HSCPs), new governance models. But too often, this “integration” has been structural  – not cultural, not relational, and not felt in the daily lives of those delivering or receiving support. Too often it’s been stymied by self-interest, defensiveness and protectionism – not least around who controls the money!

We forget that integration is not about structures but about shared purpose. About valuing a care worker as much as a consultant. About giving equal dignity to a social care manager and a medical director. It is about seeing the whole person – not their diagnosis, not their discharge date, but their story.

When crises hit – Covid, ‘winter’ pressures, strikes – we turn to social care to carry the burden. We need beds? Use care homes and call it step down or interim beds. We need support? Call on care workers in the community and give some more funding for a short period to reduce the demand. And yet, when the storm passes, we return to underfunding, undervaluing, and overlooking the very system that was there for us.

If we are serious—truly serious—about NHS reform, then social care must be our first priority, not our afterthought. It must be funded sustainably. Its workforce must be respected, paid fairly, and given hope. Its leaders must be included in every major decision about health reform rather than as it is now not even being in the room. Because it is only when health and social care are integrated in vision, in leadership, and in heart, that we will build a system that truly works.

Imagine a Scotland where discharge plans begin with the question: “What matters to you?” Where care workers are not scrambling for hours and minutes but shaping lives. Where the boundaries between hospital and home, GP and guardian, nurse and neighbour are softened by collaboration, not hardened by bureaucracy.

That future isn’t impossible. But it requires bravery and humility. It requires us to stop speaking about health reform as if it ends at the hospital door. And it demands that we finally, truly, put social care at the centre of our vision for wellbeing.

Until then, any reform of the NHS is like rebuilding the roof while the foundations crumble.

Donald Macaskill