In one of those calendar quirks today the 15^th July happens to be St Swithin’s Day and also the first Saturday of the Glasgow Fair. St Swithin’s Day as many of you might remember from the rhymes of childhood is a day when according to tradition, whatever the weather is like on St Swithin’s Day – whether rainy or sunny – it will continue for the next 40 days and 40 nights.

‘St Swithin’s Day, if it does rain

Full forty days, it will remain

St Swithin’s Day, if it be fair

For forty days, twill rain no more.’

Now I am no meteorologist, but I doubt the late St Swithin, the Bishop of Winchester in the 800s, has much influence over the weather. But it would not at all surprise me that on this first day of the Fair that the rain is pouring somewhere in the west.

As a child growing up the Glasgow Fair was very important. It was the time of year when my family made our annual pilgrimage to Skye to visit grandparents, and to allow my father to turn the day job into a fortnight of shearing sheep, picking potatoes and having more than the occasional dram to catch up with friends and relatives. It was also a time when it was either sweltering heat or continual rain – so good old St Swithin might have known a thing or two.

The story of the Fair is an interesting one. Historically it’s the oldest ‘Fair’ of its type and dates back to the 12^th century and indeed up until the late 19^th century markets and fairs were always held around the fields and green spaces around Glasgow Cathedral.

Before the 1960s it was commonplace for most businesses, factories and the shipyards to close on ‘Fair Friday’ to allow workers and their families to attend, and for folks to take their holidays by going “doon the watter” to the Ayrshire coast. Today whilst the name lives on people in the city take their holidays at many and diverse times to fit into a very changed pattern of work and leisure. You are likely to see many more Glaswegians in the streets of Palma and Albufeira than in Ardrossan and Troon.

The way we holiday may have changed but for many people taking a couple of weeks off in the summer has become almost a ritual. This year I have heard of families who despite the pressure of money and the cost-of-living crisis trying their best to give especially their children some time away even if it is just another part of Scotland.  I have also been having quite a few social media chats and DMs around the issue of holidays at this time of year from staff who work in social care struggling to make ends meet to older people who struggle with holidays per se both on the grounds of finance and also in the sense that their normal contacts and routines are so changed that it often leads them to feel so much more alone and lonely during the summer months.

Holidays are very often hard times for people for so many reasons. The loss of routine can be hard for all ages. The constant being together with people who you may not always get on with in new environments can be stressful. The process of travelling, staying in a new place, feeling you need to keep children entertained and amused – a lot of family holidays whilst fun can be the complete opposite. And in soaring temperatures tempers can become frayed and strained. Dealing with heat and humidity can be very hard for many people.

Like many of you I am well acquainted with SAD (seasonal affected disorder) and having worked in Orkney for a while was very aware of the impact the short days and long winter nights could have on the mental health and wellbeing of people. What I have been less well aware of is the impact of summer and of summer holidays on folks.

I recently came across a fascinating article by Michelle Pugle which explore the issue of Summertime SAD. It states that summer affected disorder whilst less common is just as serious. It argues that we all of us, not least those who support others, need to become much more aware of the impacts of summer and the holiday season on the health and wellbeing of people, not least as the impacts of global warming and climate change are worsening as the years go by.

“It’s important to remember that everyone is different, and while most seasonal episodes of depression occur in the winter, up to 30 percent of people [with seasonal depression] will experience summer depression…

People with summer-pattern seasonal affective disorder (SAD) — aka “reverse SAD” — typically experience common symptoms of depression for about four to five months each year when the weather is warmer.”

It goes on to detail the effects of such depression, such as feeling sad or low most days, having lower energy levels, losing interest in activities and relationships, insomnia, loss of appetite, agitation and restlessness.

The article also suggests some coping mechanisms which those who care for and support others might find useful including, identifying summertime triggers ( maybe the heat and humidity, loss of role, changes in family, issues of body image); make sleep a priority ( find out what helps you sleep in the hot nights and accentuate your sleep but do not try and sleep outwith normal patterns) ; develop a routine for the time and keep to it ( it can help you feel more motivated and put-together); attend and make space for your emotions; avoid the traps which can often make you depressed such as eating when you’re bored, but not hungry; playing video games or being on your phone for hours; drinking excessive amounts of alcohol); and build self-care into your routine.

Holiday time and summer-time are undeniable escapes for many but they bring burden and challenge to some and those who work in and receive social care and support are no exception.

So on St Swithin’s Day and during the Glasgow (or any other holiday) Fair let us look after ourselves and others.

Donald Macaskill

Photo by Deep Trivedi on Unsplash

The past few days has been full of events, from the 75^th anniversary of the start of the NHS, to the celebrations around the King receiving the Honours of Scotland, to the first 100 days of our new First Minister. A very busy week indeed. Sadly though the 5^th July was also the 75^th anniversary of modern social care in the UK I seemed to have missed any national celebration. But therein lies the lot of social care!

Closer to home the care home members of Scottish Care have been conducting a vote on whether or not they should accept the COSLA offer of 6% to increase the National Care Home Contract rate. You may have seen from the media statement on the Scottish Care website this morning that the decision was reluctantly made to accept the 6% though in so doing many considered that they were merely delaying their inevitable closure. What the statement also made clear is that Scottish Care, both its staff and members, frontline managers and carers will continue to campaign for a just and equitable pay settlement for the women and men who work in social care across Scotland, whether in someone’s own home or in a care home and for urgent sustainable funding.

At a personal and professional level, I have always been a seeker of compromise and consensus, believing that bringing people with you, working through the hard problems and issues of the moment, is more important than grandstanding or being constantly oppositional. Indeed, even during the largest crisis which social care delivery and people using care and support services in Scotland have faced in a lifetime, during the pandemic, personally and professionally I have sought to find common ground even in those moments of sharp disagreement. So it is that Scottish Care has entered constructively into engagement and negotiation over what is an urgent and national social care crisis.

Coming to a settlement over social care funding has always been a challenge and this year I think we all knew that with such large increases in the cost of living, in energy and food prices together with a critical shortage of nursing and care staff, that it was going to be especially hard. Care providers, whether they are small charities, private family run businesses or employee owned, are continually faced with a reality which is that workers can earn so much more outside the sector with so much less demand. The astonishing human value and affirmation that you get from working in social care has to be set against a personal financial reality that means you have to pay the bills!

It was always going to be the case that because of these pressures where local government simply did not have the monies that the whole process would need to turn to Scottish Government. Why? Because ultimately it is the central government of the day that has legal and moral responsibility for ensuring that there is enough money made available to pay social care staff and organisations who deliver care and support in its name.

To begin with we were optimistic about these discussions with the Government. After all they had recently negotiated a hugely positive Agenda for Change settlement for our nurses and other NHS staff. Indeed, social care providers recognised that this settlement effectively meant that NHS colleagues doing the same job were now getting paid nearly 20% more than their social care colleagues. And after all the Scottish Government has consistently said that social care is important, valuable, and even critical for the delivery of health and care.

Right across the social care sector the asks have been simple. Reward our amazing frontline staff with a pay settlement that treats them with dignity, respect, and professionalism. What was on the table – and now has for the moment had to be accepted – was an offer of 3.8%. All the very real benefits which the Scottish Government had achieved by introducing the Scottish Living Wage and by even going beyond it, have now effectively been lost.

But still those of us talking to Ministers and the Cabinet Secretary were optimistic. After all – surely, they would see the need for equity? Surely, they would recognise the risk that more and more staff would leave social care and thus risk the very foundations of a sector upon which the NHS and so much of Scottish society is so dependent? Surely, they would recognise the trauma for folks at the later stages in life of having their care home close because the provider could no longer pay the bills. Surely, they would want to work with us to end the blight of 15-minute homecare visit and so much more? Surely, they recognised the lack of funding at local level which would mean local authorities were not free to respond in any flexible way to the crisis on their doorsteps?

Well, we continued to have hope – after all the junior doctors were yesterday offered 12.4%; and earlier this last week we heard that NHS Scotland senior medical and dental staff and general medical practitioners will receive a 6% pay increase for this year, backdated to 1 April 2023. Constructive offers and deals and a valuing of people for the work they do. So surely the social care staff who literally gave everything during Covid and beyond – as politicians have stated – would receive equal treatment?

But despite numerous asks – the current Scottish Government has not even been able to give to employers and staff a timetable for the introduction of the £12 an hour which the First Minister promised in one of his earliest speeches away back on 18^th April. So why the ability to find urgent response to a crisis amongst the NHS and a bending over back response to alleviate their challenges and yet deafening silence and inactivity for social care staff and providers? One rule for the NHS and a completely different response to social care.

Is this an administration characterised by delay, dither and dysfunction or is there a ‘cunning’ strategic plan which they are just unable to share? Social care providers and frontline staff have probably already made up their own minds on that question. Is this a government that really cares about care or is it only a pretence for photo opportunities and political grandstanding? Is there any genuine attempt to deal with a crisis which is happening now or are we simply witnessing a desire to hide heads in the summer sands in the hope all troubles will blow over?

The care sector has had enough of the political promises, the empty words, the feigned sympathy and understanding; we need action, decision, and determination to really make the changes that will value our workers and maintain our organisations.

I hope with the opportunity to reflect that we can really move things forward in the next weeks and months. The alternative is a deepening social care crisis made all the worse by avoidance. The alternative is quite frankly more care homes shut, more homecare organisations lost, more staff leaving for ever , and most importantly more lives diminished and devalued amongst those supported and cared for.

Donald Macaskill

Photo on Unsplash

This coming week is Alcohol Awareness Week which is an annual event run under the auspices of Alcohol Change UK. It is an event designed to change our relationship to alcohol and this year the focus and theme is on ‘alcohol and cost.’

Alcohol brings with it some very real costs, both personally, in terms of families as well as societal and community costs.

Alcohol Change state that:

‘The total social cost of alcohol to society is estimated to be at least £21 billion each year. We as individuals also spend tens of thousands of pounds on average on alcohol over the course of a lifetime.’

In the last week a whole host of organisations and clinicians in Scotland have published a call to not only maintain Scotland’s current Minimum Unit Pricing (MUP) policy but to improve it as our MSPs begin to reflect on its continuation. Thirty-four organisations including the BMA Scotland, the Royal College of Physicians of Edinburgh, and the Royal College of General Practitioners have called for restrictions on alcohol marketing, an increase in the minimum price from 50p a unit to at least 65p, a levy imposed on alcohol retailers to fund local prevention and treatment and substantial investment in alcohol support services.

This call comes on the back of new research from Public Health Scotland which shows that the MUP policy had reduced alcohol-related deaths and hospital admissions and had lowered alcohol consumption. The new report said that MUP had reduced deaths directly caused by alcohol consumption by 13.4% and hospital admissions by 4.1% and that the largest reductions were seen in men and those living in the 40% most deprived areas.

Whilst the economic costs of alcohol dependency and use are significant it is always the personal costs that are felt most acutely. Deaths from alcohol across the UK have gone up since the start of the pandemic and there are many more individuals who are living with worsened mental and physical health every day because of harmful drinking. As well as the pandemic the current cost of living crisis and anxiety over income are resulting in many people turning to alcohol.

Scottish society has always had an uneasy relationship with alcohol and sadly there are still too many people dying from the effects of alcohol consumption, and still too many individuals and families blighted by addiction to alcohol. One group that is often forgotten about when we reflect on alcohol dependency and addiction are older people. But those who work on the frontline of care and support frequently recognise the signs of a dependency and addiction that strips people of purpose, health and wellbeing. The crippling loneliness which many of our older fellow Scots are living with in these days is often one which some chose to fill with the illusory comfort and escapism which comes from a bottle. This is not being helped by the savage cuts at local level which are leading to the closure of older people day centres and a reduction in opportunities for folks to get out of the house. Nor is it being helped by the disproportionate impact of the cost of living crisis upon older people in specific.

Yet despite the data and the numbers, the research and the knowledge, there is often an uncomfortable silence around talking about alcohol and its impact on Scottish society. To call into question its value and impact sometimes risks the commentator running the accusation of being a Calvinistic kill-joy. The stereotypical image of a drunk Scotsman (or woman) much beloved by comedy-writers of the 70s and 80s may no longer be the central image of the Scottish persona but our close association with alcohol remains a popular aspect of our international reputation and seems to be a badge of character held with pride by some.

The See Beyond, See the Lives campaign which was launched in Scotland some weeks ago is much to be praised. It seeks to tell the story of the impact of drug and alcohol on ordinary lives. Like it or not there still remains a painful stigma around alcohol and drug deaths in Scotland and the collective silence that results from that prevents us from having a proper, open and honest discussion about alcohol and drugs. Those who have taken part in the campaign are much to be applauded, as it focusses on getting people to write letters to those loved ones who have died. Two of those who have taken part are the two MSPs Miles Briggs and Monica Lennon who have written letters to their late fathers. They both tell their first-hand experiences as the children of fathers who drank.

In 2021 there were 1245 alcohol-specific deaths in Scotland. These deaths leave families torn apart, relationships ended and lives and hopes empty. They and the thousands upon thousands before them were avoidable.

I have been around alcohol addiction for most of my personal and professional life. It has a power over people which at times appears to be inescapable as it pushes hope and warmth and love into the dark corners of living, as it turns gentleness into anger and calmness into chaos. It makes a child cower in the corner fearful of unpredictable wrath and brings hunger and emptiness where there could have been a house full of love and touch. It feeds on a culture amused by its impact on the one hand and yet incapable of talking about real harms on the other.

My hope this Alcohol Awareness Week is that we all of us start to talk a lot more about alcohol and its impact on our society, not least the growing alcohol dependency amongst our older population which in too many instances is going unnoticed and unrecognised.

As many of you know I love poetry and it has always fascinated me how few poems there are telling of the pain and distress brought about by alcohol addiction compared to those extolling the delights of drink. But one I came across some time ago really speaks of the harm of the booze though I would counter its lack of hope by saying that for some if not all there can be angels who attend unto the end. It is The Silence by the Pulitzer Prize winning American contemporary poet Philip Schultz

for RJ

You always called late and drunk,
your voice luxurious with pain,
I, tightly wrapped in dreaming,
listening as if to a ghost.

Tonight a friend called to say your body
was found in your apartment, where
it had lain for days. You’d lost your job,
stopped writing, saw nobody for weeks.
Your heart, he said. Drink had destroyed you.

We met in a college town, first teaching jobs,
poems flowing from a grief we enshrined
with myth and alcohol. I envied the way
women looked at you, a bear blunt with rage,
tearing through an ever-darkening wood.

Once we traded poems like photos of women
whose beauty tested God’s faith. ‘Read this one
about how friendship among the young can’t last,
it will rip your heart out of your chest!’

Once you called to say J was leaving,
the pain stuck in your throat like a razor blade.
A woman was calling me back to bed
so I said I’d call back. But I never did.

The deep forlorn smell of moss and pine
behind your stone house, you strumming
and singing Lorca, Vallejo, De Andrade,
as if each syllable tasted of blood,
as if you had all the time in the world. . .

You knew your angels loved you
but you also knew they would leave
someone they could not save.

Copyright © 2002 by Philip Schultz.

https://poets.org/poem/silence-0

Photo by Kajetan Sumila on Unsplash

Donald Macaskill

There are times when in the midst of all the flurry of publications, reports and essays something appears and often falls under the radar because there is so much happening at the same time. In a week where we have witnessed huge debates in the UK Parliament over a former Prime Minister, a launch of a new approach to independence from the Scottish Government and ongoing issues over health and social care, a couple of days ago the Scottish Government published a framework with a whole set of recommendations called: Discovering meaning, purpose and hope through person centred wellbeing and spiritual care: framework.

It might not be on the top of everybody’s weekend reading but might I suggest it should be. I need to be upfront and declare an interest because I had the privilege of chairing one of the small working groups who fed in ideas and views from the social care and health sectors into what the report contains. But I have honestly to say that it is a great read, its recommendations clear and concise, and it has the potential to really change and add maturity to the way in which people are supported both in social care and in health services – if we grant an adequacy of resource and priority to embedding its suggestions.

Now I fully accept that in the midst of a funding crisis, at a time when we are struggling to recruit and retain social care and indeed health care staff, when the burden of regulation and requirement is breaking the back of so many in our care and support leadership – that a report with a whole host of more things to do and implement might seem to be as welcome as a sunbed in the Sahara but I think that would be an unfortunate dismissal of a report which can indirectly address some of our current system and workforce pressures.

But at the start of any discussion on spiritual care we have to address the issue of its definition and its relevance especially when so many people equate spiritual care directly and exclusively with religious faith and tradition. The report helpfully seeks to do both. The Ministerial introduction states:

‘Historically, spiritual care and religious care were one and the same, but that is no longer the case. Spiritual care is there to help all who need it, regardless of their personal faith, beliefs or life stance. Spiritual care doesn’t fit easily into traditional models of care and, at times, in our modern world some may struggle to see or understand the relevance of spiritual care in our health and social care system. Spiritual care supports people by acknowledging hopes and fears and building resilience to cope with challenging or changing circumstances. Spiritual care helps us to connect to deeply held values and beliefs which inform our life, our work and our relationships. It is in the context of such relationships that questions around change, identity, illness and loss can be explored. It enables carers and those cared for to walk together as companions, supporting each other when life is raw and painful, or our certainties are shaken. Such mutually beneficial and respectful relationships must be at the heart of our health and social care system, allowing individuals to be heard and valued.’   (page 4)

When I have myself written about why I believe spiritual care is of fundamental importance and why its receipt should be viewed as a human right, I have been very aware of the extent to which trying to define it can feel like trying to grab hold of a jelly on the one hand and that trying to sharply define and designate it feels like doing a disservice to its very essence. The report captures this well when it states:

‘We all have a part of us that seeks to discover meaning, purpose and hope in those aspects of our experience that matter most to us. This is often referred to as “spirituality”; informing our personal values and beliefs, and affirming that tears, laughter, pain, and joy are all part of the human experience.

It is recognised that the spiritual is a natural and integral dimension of what it means to be human. Within health and social care, it is widely accepted that questions of meaning, purpose, hope (or the lack of it), identity and relationships can become acute when wellbeing and stability are challenged or threatened by illness, injury, or loss in oneself or in a loved one. At such times people often need spiritual care.’ (page 5)

We are all of us more than the raw bones and sinew, the flesh and mechanics of our human body and frame. Spirituality has to do with the heart and pulse of being human. It is the soundless language which communicates our deepest emotions of love, anger, fear and belonging. It is the rhythm which gives form to many of our innermost thoughts and feelings. It is the space where we rest in the awareness of meaning beyond comprehension and experience beyond description. To offer spiritual care is to give opportunity, time and place to enable an individual to explore and to express who they are as a human individual. It is at the hard times and moments, the transitions of living and loving that spiritual care finds sharper relevance and poignancy but I would suggest it has relevance in all moments when care and support is exchanged.

A set of Expert Working Groups on key topics within spiritual care was established by Scottish Government and through their work the Report makes specific recommendations developed around four key areas of focus:

• A skilled and compassionate workforce
• The development of spiritual care in community and social care settings
• Data collection and evidence base
• A professional specialist workforce.

I am not going to rehearse all of the recommendations here, but I am delighted that there is such a clear focus and emphasis upon social care within the report.  Historically spiritual care was mainly centred upon and delivered in acute and secondary care settings. As a past occurrence that is understandable but is no longer defensible as we increasingly recognise and live with the inter-reality of health and social care in our personal and professional lives. Spiritual care has to speak to the delivery of clinical care in the community as well as to social and primary care delivery.

However, this re-orientation of emphasis and focus should not be at the expense of the generations of work undertaken in hospitals but rather spiritual care in the community and in social care should seek to build upon that expertise and knowledge.

The first recommendation of the framework puts it as plainly as is possible:

‘Recommendation 1: Health and social care providers should ensure that spiritual aspects of care are assessed, recorded and regularly reviewed within care plans in all health and care settings and services.’  (page 10)

Spiritual care is not an added extra, something to be thought of when all else is ticked off, but rather it is intrinsic to holistic care and support because it addresses the whole person.

The report describes the implications of what this widening of scope and focus means for our social care system from commissioning, workforce development and capacity through to regulatory oversight and inspection. It has many recommendations, but they will only take flight and have any impact if they are owned and championed by the leaders and professionals working in our social care sector and understood by the citizens who receive care and support as their right and obligation.

That may take some time, but it starts with an honest conversation that challenges stereotypes and builds an appreciation of the unique and irreplaceable contribution of spiritual care within the delivery of all care and support. It will involve discovering whether the tools and techniques being used in spiritual care from Community Chaplaincy Listening to Values Based Reflective Practice speak to a different context such as care homes or homecare and housing support services. It will necessitate an investment not just in changing induction programmes and developing training resources but sitting down with the women and men who deliver the diverse range of social care supports and care and discovering what works for them and what makes the translation from recommendation into implementation a reality. Critically it will require commissioners and funders at times of straitened economic pressure to appreciate that spiritual care is not a marginal priority but intrinsic to modern rights-based, person-led, social care and support. Lastly and perhaps most critically for the workforce it will require frontline staff to be supported to be open to the discovery that spiritual care is something which can add benefit and value to their own wellbeing as well as to their art of caring for others.

I strongly encourage you to read the report and its recommendations. If it succeeds as I feel, it will put Scotland at the forefront of this work, but it will also achieve what it states, namely to ensure that it firmly establishes the role of spiritual care as an integral part of health and social care provision.

A few weeks ago, I went to visit the National Trust of Scotland property, the Weaver’s Cottage in Kilbarchan, Renfrewshire. It was truly fascinating and was an eye opener into both the significance and role of weaving in the Scottish economy both traditionally and still today. I found the weaving looms intriguing as they conjured up for me the memories of childhood when I can remember seeing smaller versions of traditional looms in the islands.

Weaving can be used as a metaphor for many things but as I read this report and reflected upon it the image of the weaving looms, I saw a few weeks ago came to mind. Someone who supports another through the art of delivering spiritual care takes the threads of living and loving, the fractures of memory and regret, the colours of joy and tear, into their hand and helps the person being supported blend them together into the rich and unique fabric of individual living. That might have an added poignancy in a life that is nearing its end, but it has value at all times.

Spiritual care if delivered well helps to integrate all the aspects of our identity into a unity of character and personhood; it leaves space for our growth and the discovery of new patterns and ways of being who we are both for ourselves and others. But having visited Kilbarchan I know how much hard work is involved in the art of weaving. If we are as individuals and as a society in Scotland to discover meaning, purpose and hope through person centred health and social care in all settings and places then the recommendations in this framework report can only be the start of all the hard, collective and shared work required to weave a cloth whose pattern is even today being created in the lives of those supported and cared for across Scotland.

Donald Macaskill

There is something of a delicious Scottish irony that after weeks of continual sunshine and at the end of a week in which an official heatwave was recorded for many parts of Scotland that I am sitting writing this blog watching the puddles outside after a night of rain on a day when lots of local community outside events are due to take place! The irony is not in the ability of the Scottish weather to potentially announce the end of summer before June is over but in the fact that today is a day which the United Nations annually designates as the World Day to Combat Desertification and Drought.

As the UN states

“Droughts are among the greatest threats to sustainable development, especially in developing countries, but increasingly so in developed nations too. In fact, forecasts estimate that by 2050 droughts may affect over three-quarters of the world’s population.

The number and duration of droughts has increased by 29 percent since 2000, as compared to the two previous decades (WMO 2021). When more than 2.3 billion people already face water stress, this is a huge problem.”

The theme for this 2023 is Her Land, Her Rights and is a recognition of the reality that women the world over ‘hold a vital stake in the health of the land, yet they often don’t have control over it’…. And that ‘investing in women’s equal access to land and associated assets is a direct investment in their future and the future of humanity. It’s time for women and girls to be at the forefront of global land restoration and drought resilience efforts.’

The truth of climate change is an ever-present reality right across the world and Scotland is evidencing that painful reality all too frequently. Wild-fires and water shortage, droughts and ruined crops are all indicative of dramatic changes to our environment and are individually and collectively clarion calls for urgent action on climate and sustainable resources.

Whilst the UN focus is quite rightly on women and the significant role, they could play in both land use and in challenging drought and desertification, I am very mindful these last few weeks of the dramatic impacts our changing patterns of weather are having on older Scots.

From a young age I’ve always been fascinated by the weather. It was probably inevitable that I’d become a weather obsessive because it feels like it’s in the blood perhaps because of a long ancestry of farming and island life. In fact, there was a long-standing family joke that my mother’s first words in any conversation in response to the usual ‘How are you?’ was for her to tell you what the weather was like. Maybe it’s the unpredictability of the weather in Scotland that has always held my interest and indeed I’ve blogged about the truth behind the reality not least in Skye of how you can and often do get four seasons in one day as the words of Crowded House’s hit made famous.

But there is increasingly a new dimension to the unpredictability of weather which should cause us more than inconvenience it should convince us to be concerned enough to take action.

The dramatic changes in our weather seem to be happening far sooner than many of us might have predicted and their effects are already significant.

I’ve had numerous conversations with care staff and older folks in the last few weeks of intense heat and sunshine about how hard it is to be old and to live with health and care needs in periods of intense weather.

Indeed, there is an increased awareness that high temperatures and heat can have a profound and sadly fatal impact on many people. Heat warnings from the Met Office are a new phenomenon but we are now witnessing them on our weather forecasts much more often.

Extremes of weather demand our attention in numerous ways. One is to address at national and local level the requirement to change the way we treat the environment to avoid the worst excesses of poor land management that can lead to flood or indeed drought and water shortage. This last week there has also been parliamentary and political debate about who we transition to a low carbon and Net Zero economy not least in energy use and house construction.

At a more personal and local level I do think as a whole society we need to focus on how we keep ourselves healthy in the likely instances of more extreme weather. That in part includes all of us being aware of practical steps as detailed by the Met Office and organisations like Age Scotland. Whether it is through making sure we support neighbours and relatives to be aware of the importance of drinking lots of water or avoiding being out at the hottest part of the day we need to become weather and climate resilient communities.

But there are also much wider considerations which in my view we have not even begun to prepare for. On this international day when we are aware of the impact of drought on some of our most vulnerable communities and parts of the world, I think we need to give serious consideration to a climate action plan which specifically addresses the needs of an ageing population which is our reality in Scotland.

As more and more people live longer but also live alone we need to ensure that social care and support, and wider community support is focussed to and capable of addressing specific seasonal climactic needs. That might include re-design of our built environment to improve ventilation and temperature management. It certainly needs to include equipping frontline staff with knowledge to recognise signs of dehydration or early risks of cold weather impacts. It demands our housing sector to start to construct for demographic reality rather than maximised profit. I’ve lost count of the number of planning proposals which on paper seek to build single person and accessible accommodation but which when construction ends are invisible because it is argued that they are expensive to build and margins are low.

Right across the board from planning to social care, from educating our young on climactic response to allow them to support all to live safely in our communities to investing in climate technological innovation there is a serious lack of focus on the specific climactic management needs of older persons.

I’ve probably lost faith in the hope of ever finding a truly accurate weather forecast though that’s not stopped me downloading every new app, but it doesn’t take much to forecast the reality of increasing climactic unpredictability. Our response to that could be to ostrich-like hide our heads in the sands or to begin to develop, plan and implement robust and resourced age-sensitive climate action plans. It’s quite clear to me that those most at risk are our elderly fellow citizens and it is with them that our response needs to start.

These last few days as hot weather has stretched beyond expectations, I’ve heard quite a few folk engaging in the ancient Scottish pastime of negative weather prophecy (and I include myself here!) from suggesting that this is us having had our summer to a conviction that “we will pay for it.”! But we all still have the agency to do something about preparing ourselves and our population in older age to be healthy in a world of changed climate.

I leave you with my favourite poem about our Scottish weather by Alistair Reid. Enjoy whatever weather the day brings you and yours.

‘Scotland’ by Alastair Reid

It was a day peculiar to this piece of the planet,
when larks rose on long thin strings of singing
and the air shifted with the shimmer of actual angels.
Greenness entered the body. The grasses
shivered with presences, and sunlight
stayed like a halo on hair and heather and hills.
Walking into town, I saw, in a radiant raincoat,
the woman from the fish-shop. ‘What a day it is!’
cried I, like a sunstruck madman.
And what did she have to say for it?
Her brow grew bleak, her ancestors raged in their graves
as she spoke with their ancient misery:
‘We’ll pay for it, we’ll pay for it, we’ll pay for it!’

from Inside Out – Selected Poetry and Translations (Edinburgh: Polygon, 2008)

https://www.scottishpoetrylibrary.org.uk/poem/scotland-1/

Photo by NOAA on Unsplash

Donald Macaskill

There are so many lonely people who spend their time in the company of absence; whose only conversation is with emptiness. I’ve met many of them.

Monday sees the start of Loneliness Awareness Week 2023, which runs till the 18th of June. Established by the Marmalade Trust it aims to raise awareness of loneliness in the UK and worldwide. This year’s theme ‘Connection Matters’ promotes small everyday moments of connection to reduce feelings of loneliness.

The statistics about loneliness are well known. Tens of thousands of people when asked say that they are lonely. It is an experience which knows no age or other demographic characteristics but seems to impact on a growing number of people. Indeed according to the Marmalade Trust, a recent survey from King’s College London, The Policy Institute and IPOS, found ‘that almost a third of people in the UK feel lonelier since the pandemic. Loneliness is also believed to be costing the UK economy around £32 billion every year due to the cost-of-living crisis and disconnected communities.’

The UK Government has a dedicated Minister for Loneliness whilst in Scotland Emma Ruddock who is the Minister for Equalities, Migration and Refugees, has Social Isolation and Loneliness as one of her eight areas of responsibility.

I’ve written elsewhere about the impact of loneliness not least upon older people. In trying to describe what it felt like I wrote:

‘Loneliness is not just the absence of others rather it is that emptiness created by absence which reaches inside a person and holds them. It is the sense of physical and emotional abandonment and complete aloneness; the sense that no one is there for you, no one is listening to you, and no one is truly hearing you. That tragically is what too many feel today. A social care system worthy of its name should seek to support and uphold not just by care but by being ‘social.’

There are many reasons why people are lonely, but the one I want to briefly focus on this week is the loneliness which comes because of grief. For if there is any hierarchy of emptiness then the loss felt when someone leaves your life forever is perhaps the most acute.

Someone once said to me when she was describing how lonely she was after her husband of 28 years had died that she felt as if she had the ‘core of my being hollowed out just as I’d core an apple. There is something missing and I’m unable to put myself together again.’

The hollowing out of our self which is the result of the death of love will be known to many. It is an emptying of hope and aspiration, a directionless yearning for a world of lost assurance and dream; it is a hunger that no nourishment will fill; a pain no comfort will assuage.

It is a hollowing which is of acute and sharp pain; the loss of a partner leaving you to parent children who will grow up with the ache of absence; the loss of someone who you have cared for through illness and disease leaving you now emptied of the familiar rhythms of care; the loss of someone in whose company you could be who you really are, without the need for the weariness of pretence or explanation. The loss of a smell that made you feel all warm inside; the silence of a timbre of voice that was like the best days of memory; the loss of all those moments when you could rest in your being together.

I often hear folks saying to the bereaved that it is important to not be alone, to busy yourself with activity and to distract yourself from the thoughts of grief inside your head. With respect I think this is wrong. I think there is a difference between an aloneness which helps to heal and re-orientate your living and loneliness which brings separation and breaks connection.

An important part of grief is sitting with the pain of absence. Maybe it is just me but there are times when my grief needs my whole being to be alone. This aloneness is cradling the knowledge that you will never again be with the person you love; that their voice is the murmur of love inside your bones. And that terrible and terrifying though it be that it is natural to feel lonely and abandoned, but also that this will one day become a world in which you can live again and do more than simply exist. So it is that  I believe that there is difference between the aloneness of grief and a loneliness which causes you harm and stops you grieving properly.

Loneliness Week is right to emphasise the importance of connection – it is vital to who we are as human beings that we belong in place and with others. But it is also important that connection is authentic and real and that we connect with others when the time is right and when we have reached that stage in our bereavement walk. We cannot manufacture connection and the rush to restore ‘normality’ and diminish pain can cause unnecessary hurt and harm. If I know anything about my own travelling through the landscape of loss it is that every single person’s journey is unique and whilst there are similarities, we never walk the same steps and there can never be a replica of sameness to grieving. We cannot rush someone through grief as if there are key staging posts to be reached and a destination to be achieved.

That is not to deny that there are indeed lessons for those of us who sit alongside the bereaved which might address and lessen some of the loneliness that is felt and experienced and which causes harm. One such is the simple acknowledgement that with death comes a whole host of losses for the bereaved. You might no longer feel connected or involved in the groups and activities which you shared or went to together; carers especially feel a sense of loss when their sense of identity is replaced virtually overnight. The journey from carer to bereaved is a sudden and sharp one for which there is often so little preparation or planning. There are also too many for whom invitations dry up because folks feel awkward about encroaching on ‘grief’ or don’t know how a ‘single bereaved’ person fits into their perception of social normality. More recently the effect of the cost-of-living crisis has made it harder for people to be able to ‘re-connect’ with others because they cannot afford to travel or socialise.

Grief can sometimes make us feel like we are outside ourselves watching someone in our own body going through the motions of routine and normality whilst we know deep inside that all is changed forever. It is a twilight zone where nothing feels substantial and solid; no matter how hard we try to grasp it life trickles through our fingers.

When you are in the grief of loneliness a crowded and busy room can feel empty and silent. You observe but there is no real contact, folks talk but there is no real connection. In such a place loneliness is your state of being but aloneness might sometimes be your solace.

The Tea Break:

She sits

quiet and held tight

into herself;

watchful and waiting,

listening and remembering.

Gossips parade their barbs

and coffee-drenched tongues

salivate over salacious sensation,

and still she sits.

Empty words fill the silence;

meaningless intelligence

make a nonsense of conversation,

and still she sits.

Diets and crosswords,

fashion and fantasies,

empty lives shared

and still she sits.

Careless chatter crackles

in a tea room of

folk fearful of friendship

and still she sits.

Not a stir

Not a flutter

Not a movement

And still she sits

In the tea break.

Donald Macaskill

Photo by Geoffroy Hauwen on Unsplash

Dire warnings about the end of the world are normally the stuff of placard bearing street preachers prophesying Old Testament style global ending but in the last week mainstream media has been carrying concerns about imminent extinction. The source of such threat not inter-galactic invasion or even ecological catastrophe but a very human development, Artificial Intelligence.

When I first wrote at length about AI and its role in the world of social care there were even at that time some highly respected scientists who were warning about the threats together with advocating the potential of AI. Stephen Hawking even told the BBC in 2014 that “The development of full artificial intelligence could spell the end of the human race.”

This past week a popular British newspaper was amongst many who stated:

“A dramatic statement signed by international experts says AI should be prioritised alongside other extinction risks such as nuclear war and pandemics.

Signatories include dozens of academics, senior bosses at companies including Google DeepMind, the co-founder of Skype, and Sam Altman, chief executive of ChatGPT-maker OpenAI.

Another signatory is Geoffrey Hinton, sometimes nicknamed the ‘Godfather of AI’, who recently resigned from his job at Google, saying that ‘bad actors’ will use new AI technologies to harm others and that the tools he helped to create could spell the end of humanity.”

As well as the prospect of human extinction there are also some more immediate perceived challenges brought about by the increased use and dependency upon AI and chief amongst them is the impact on the workforce in certain industries. This was evidenced in the much-publicised news a few weeks ago that British Telecom would be laying off thousands of workers and that a fifth of those job cuts will come in customer services as staff are replaced by technologies. BT Chief Executive Philip Jansen stated:

“Whenever you get new technologies you can get big changes,”

“generative AI” tools such as ChatGPT – which can write essays, scripts, poems, and solve computer coding in a human-like way – “gives us confidence we can go even further”.

Mr Jansen said AI would make services faster, better and more seamless, adding that the changes would not mean customers will “feel like they are dealing with robots.”

Balancing the voices of pessimism are those like Stephen Marche who writing in the Guardian stated:

“In the field of artificial intelligence, doomerism is as natural as an echo. Every development in the field, or to be more precise every development that the public notices, immediately generates an apocalyptic reaction. The fear is natural enough; it comes partly from the lizard-brain part of us that resists whatever is new and strange, and partly from the movies, which have instructed us, for a century, that artificial intelligence will take the form of an angry god that wants to destroy all humanity.”

In Scotland this past week the Innovation Minister Richard Lochead addressing the Parliament stated:

“These tools, known as “Generative AI”, will have an impact on jobs.

… for example, OpenAI claims that GPT-4 can achieve the same as a top 10% law student in bar exams.

… But it is important to not lose perspective on AI.  Most experts do not believe AI will be able to supersede human intelligence without several new breakthroughs, and no one knows if or when those will happen.  At the moment, talk of an impending “singularity” which means machines thinking for themselves without needing humans still involves a large dose of fiction. Essentially, for now at least, AI is just a tool.”

So, has any of this got anything to do with the world of social care and support? Is there threat or potential from AI or is the true reality something much more nuanced and complex? In the midst of massive global challenges around workforce and sustainable and affordable social care systems; in a world where more of us are living longer and seeking to achieve the benefits of positive ageing, is AI a trap or a panacea?

Certainly, there are some politicians whose imaginations seem to have been captured by the prospect of fiscal savings and workforce re-design on the back of AI and the Internet of Things. Most prominent amongst these new converts and evangelical prophets of a new tomorrow in social care and health has been Steve Barclay the current UK Health Secretary. Barclay spoke to the Daily Telegraph and suggested that having been inspired by a recent trip to Japan that the dawn of new social care possibility was coming soon.

“The health minister suggested robots and AI can help in better supporting patients and reducing demand on health and social care staff.

He said there was a need to consider and adopt other nations’ “innovative” approaches to health as the UK government attempts to cut NHS waiting times after Covid-19 and improve care for the elderly.

Mr Barclay said the Japanese were “world leaders in their use of tech” and that they have invested in a wide range of technologies, including robotics, “as a key way of getting care to patients,” adding “that is something we can learn from”.

Silver Wing uses several types of robots in its care homes. At its Shin-tomi nursing home in Tokyo, humanoid talking robots interact with patients, including those with dementia, and lead them through various recreational activities.

Other robots monitor patients as they sleep, alerting caregivers if the individual is agitated or attempting to rise out of bed. One robot also assists carers as they lift patients out of their beds and into wheelchairs, a physically demanding task.”

The article also details the extensive growth in the use of care bots across Japan:

“In the year to March 2017, £39.5 million was spent by the Japanese government to introduce robots into 5,000 facilities across the country. By 2018, an excess of £236 million had been spent on funding the research and development of such devices…

Japan has been investing in the development of elder care robots to help fill a projected shortfall of 380,000 specialised workers by 2025.”

All very appealing but I think we need to go beneath the surface of the hyperbole of ‘care-bots’ and AI not least in that we are operating with very different cultural and societal attitudes to ageing and the place of the older person in community and family.

There is an inescapable reality that in Scotland we are ageing as a whole population and that with little inward migration (even from other parts of the United Kingdom) this is likely to be an inescapable trend. We will need to alter the way in which we deliver social care and our dependence upon a human workforce is part of that reappraisal. I have long advocated that there is real potential in the use of in-home technology to enhance preventative care and support, promote self-management and to increase independence. It is self-evident that technologies including those utilising AI will be central to this fostering and enabling of greater in-home independence. It is also a truism that we will increasingly see the use of robotics (care-bots) in residential and nursing home settings although earlier hype needs to be balanced both by resource and investment reality and by demand. For instance the much vaunted ‘Pepper, robot is no longer being manufactured.

The Scottish Care driven project ‘Care Technologists’ is at the heart of embedding technological solutions within a human-rights based and person-led model of supported living and care home use.

As AI develops at an even faster pace there will be some tasks in a care home or supported individual’s home which can be both accelerated and automated. We are seeing some organisations investing not insignificant sums in introducing innovations which reduce time, remove duplication and introduce consistency. But in the most human of industries and sectors such as social care questions need to be asked about the boundaries and constraints that are required to ensure a human rights based and citizen controlled use of care technologies and AI.

So there are companies already utilising AI to write care plans for an individual by utilising existing models, predictive responses and assimilating with personal data. But is a care plan not something more than a tick-box, pro-forma exercise? Is it not also a plan for living and support which arises from the formation of relationship which enables instinctive and intuitive skill-based dialogue to occur and happen. I have lost count of the number of assessors and clinical and care practitioners who have over the years told me that it is not so much what someone says and discloses in an assessment interview that matters, but their mannerism and mood, their engagement or otherwise in an encounter, that influences the exchange. The oft quoted comment that we learn as much from what is not said or how someone expresses themselves is perhaps not so easy to calculate algorithmically by a machine.

It is also true that many care settings are increasingly using care-bots to provide company and reduce isolation, to act as tools of reminiscence for people who would otherwise be alone or distressed. But what are the limits of such usage? Growing old is not just about remembering the past but re-shaping and re-forming a future which is surely something which we do best in human relational interaction and exchange?

And thirdly, a point I have made in numerous contexts, at those ultimate moments of living and loving, is a technological presence, a care-bot what we want? Can a machine soothe distress or grant assurance, reduce fear, or bestow solace? And even if the answer to these questions is yes, the question remains as to whether in a human society shaped by dignity, they should? Just because something is possible does not make it desirable.

That is why framing the use of AI in social care and health settings and relationships becomes a primary question of the moment. It is why we need to pay attention to work which seeks to frame AI within a human rights context because there is more than enough evidence of biases and discrimination in its potential use, not least for the older citizen. A world first study on ageism in AI published by Monash University in Australia a couple of months ago makes for worrying reading. As the lead author of the study Dr Barbara Barbosa Neves states:

“AI can perpetuate ageism and exacerbate existing social inequalities,”

“When implementing AI technologies in aged care, we must consider them as part of a suite of care services and not as isolated solutions.”  And

“The use of AI in aged care must be done with consideration of the potential impact of these technologies on well-being, autonomy, and dignity of older residents.”

A human rights based approach to AI is critical to its success in social care and it is wholly erroneous to equate a human rights based approach with an ethical approach – the two are palpably not the same. I would commend the work of Scottish Care, VOX and the Alliance and other partners in this field together with the publication ‘ A Digital Cage is still a cage.’  and the succinctly practical ‘If I Knew Then What I Know Now.’  But we need more of these approaches and boundary setting maps of our AI reality.

In all that I have read recently about technology and AI and the changes it might bring about for the workforce and those who receive care, one recent article has for me got to the heart of the potential of AI to change the dynamics of human relatedness and in particular caregiving. Emily Kenway writing in the Guardian a couple of Sundays ago, in a movingly insightful piece writes:

“… are we missing something about the potential impact of these technologies on caregiving?…

Patience, confidence, purpose – it seems that caregiving generates faculties many of us consider desirable. Perhaps caregivers know something under-recognised in discussions of care and tech: that care, like love, is multidimensional – the good and the difficult coexist.

Prof Shannon Vallor is concerned that the brave new world of care tech has overlooked this dimension of caregiving in its laser-like focus on alleviating hardships. Her work as a philosopher of technology, currently at the Edinburgh Futures Institute, is drawing our attention to the ways in which jettisoning care to the machines might mean we lose important capabilities.

There is a paradox at the heart of care tech. If Vallor is right, then caregiving is a crucial route through which we can help realise our humanity. The “benefits of being a caregiver scale”, and the growing body of evidence underpinning its development, suggest she might be. In this case, the technologies being developed on behalf of caregivers to free them from their “burden” may have an unexpected cost: the loss of important human capabilities. But experts are clear that technology can be vital for reducing caregivers’ load, too. Paradoxically, then, while tech may prevent us reaping the rewards of caregiving, it may also enable them.”

I have much less concern about global annihilation being the gift of AI but am more concerned at the loss of the dynamic of care and relatedness which might by default and lack of planning result from it. The human race may not be at risk from AI but our humanness just might.

Donald Macaskill

I’ve spent more than my usual time this past week in TV studios, speaking to journalists and doing interviews. The reason has been a media statement published by Scottish Care about the current state of discussions around the National Care Home Contract. In some of these interviews I mentioned as I have before both in discussions and in this blog that care homes are having to close their doors because they cannot make ends meet. I’m not going to go over the nuts and bolts of those decisions and discussions here, but I want to briefly this week share something of the impact upon those who are in a care home when a decision is made to close.

The first thing to say is that you can never generalise about the closure of a care home. They happen for many reasons but more recently they have been happening on the grounds of cost and sustainability. A recent example of this is one which for me comes very close to home.

Around a month ago the news broke that one of the oldest charities in Glasgow had announced it is to close and carefully wind-down the running of its care home in the west end of Glasgow after nearly 200 years. This was the first care home I ever visited – as a primary school pupil in a nearby school. Even then I was impressed by the palpable sense of love and compassion in the place. I remember going home and saying that it was a ‘special place.’  I have visited friends, acquaintances, and neighbours over the years in the home, a place which I walked by most weeks of my early life. The depth of compassion, of life lived before the end, of family welcome were so memorable – yet after all the challenges of the decades including the hell which was Covid-19 the home is to close. Media coverage stating the reasons as:

“severe and unsustainable cash flow problems stemming from the rising costs and challenges of running a major care facility”, the administrators said.

This included staff shortages, costs of sourcing agency staff, rising food and energy bills, compliance costs and falling occupancy levels.”

I will miss Balmanno House but sadly I know and have been told of so many more care homes which have had to close primarily because of staffing and recruitment costs, of sustainability around energy and other commodities – and all because of an inadequate level of public funding. Closures which hit the local media, but which are going largely unnoticed amidst all the political grandstanding and front-page headlines of recent days and weeks.

It is a generally received wisdom that when a care home closes it has a negative impact on staff and most importantly residents even in shortening life and decreasing wellbeing. That is certainly the anecdotal wisdom of many families and those who work in the sector. Prof Jon Glasby of Birmingham has and is undertaking research in the area and suggests that that may not always be the case if the care home had poor quality provision before its closure. Glasby’s research is probably accurate but what is happening up and down the country these last few months and especially in rural and remote areas is not the closure of homes which were in decline but that high quality care homes are having to close not because they are providing a poor service but because they cannot afford to stay open or cannot get staff. That is very different. The trauma and upset of dislocation from a place of contentment is much sharper and rawer than leaving a place of dissatisfaction.

I want to briefly share some of the conversations I have been having with staff, managers and families in the last few weeks and months because sometimes when you hear about a care home close or when you read numbers and statistics, we can fail to understand the experience and lived reality behind the headline.

Mary was a resident in the care home for five years and when she entered the home she really didn’t want to be there and on her own admission she gave the staff hell because she was so desperate to get home and thought that her daughter had abandoned her. But with perseverance and positivity the staff nurtured Mary’s confidence and slowly as she puts it ‘the ice thawed’ and she began to settle in – indeed it only took a couple of weeks. After that she openly confesses that these last few years have been amongst the best of her life. Of course, she misses her own place, but she will tell you straight out that she just was no longer able to look after herself because of her frailty and that she had had two hips replaced after falls. She was immensely lonely and had sunk deep into herself even though she had good support from homecare staff. What the care home did was to bring her back to life and much to the surprise of family and others she was thriving. She formed new friends and loved the range of activities and what she described as a constant sense of fun. The staff were brilliant but she also said that so many had left after Covid and there were many new staff or staff who only came for a short period, and this had changed the place. Then they got the news of the closure and Mary was not the only one who got really depressed and saddened.

When I met Mary she was trying to be positive for everyone around her but it struck me after years working in the fields of loss and grief that plain and simple what Mary was experiencing was a bereavement, a loss of the familiar in her new place; a loss of relationship with folks she had come to love both staff and residents because most had not followed in her steps to the new home she was now in some 20 miles from where she had been. She was determined not to be down and to fight the black mood – but what I witnessed in Mary was grief pure and simple. A grief that need not have happened, a grief for which many of the staff around her now were ill equipped to support. But more than that and Mary confessed this – she was worried about making new friends, making the effort of getting to know folks for the fear that in a few months it would all happen again. Grief is first and foremost the fracturing of love and if that brokenness is one that could have been avoided you are much more wary of being vulnerable to love.

When a care home closes its impact on residents is personal and profound. It is a loss and bereavement which we need to support but it is also one which we should all be doing as much as we can to avoid in the first place.

Jim was the manager of the care home which Mary was a resident in. To be fair Jim could see the writing on the wall as he attended the meetings of the charity trustees which ran the home. Money was not so much tight as non-existent. Donations for the small community-based charity had dried up so much and there was a black hole in them during Covid from which they never recovered. ‘Folks gave to the big causes that were on TV,’ he would say ‘not to the local places.’ The trustees made the decision to close because they simply were running out of money with all the increased costs, and they could not persuade the local authority funders to pay more for the residential care and support they provided.

Jim had over 30 years’ experience in the care sector and worked across so many different groups, but he found his niche and became a manger – indeed an award winning manager renowned for supporting staff, working closely with families and integrating the home into the life of the local school and community. But as he closed the door on the home for the last time, he told me that he could not but shed a tear for all the stories told inside its doors, all the love and loss, the sheer fun and laughter he had had inside.

Jim too was a man who was grieving – having not just lost his job – indeed he was now working outside the care sector – but having lost the place where he said to me, he had become the person he was when I met him. He was sure that the place and the people had given more to him than he had to them. It as not, in his words, just about bricks and mortar. His last act was in memory for all who had passed through the gate and door – it was to hang a wreath.

For Jim and Mary, you could count many hundreds more. Behind the closure of a care home, the dislocation of its residents and the loss of livelihood for staff, is an undoubted grieving process, a bereavement of place and memory, of folk and feelings, of special times; of safe space and held love.

In all the politics and wrangling over finance and priority, in all the debate over culpability and responsibility – I hope we never forget folks like Jim and Mary – it is their living and loving that is changed forever when a care home closes.

Donald Macaskill

 

Yesterday was the Scottish Care, Care at Home and Housing Support conference which was held in Glasgow with the theme ‘Keeping Care at Home’. It was followed by an evening Awards ceremony in which participants were able to thank the amazing women and men who have worked in homecare across the country over the last year.

The day was one which was both inspiring and also concerning because so many of the conversations I held with those who were attending underlined in the strongest terms the degree of crisis and challenge which is being faced by the homecare sector across Scotland.

Politically and societally, there is a lot of agreement about homecare. People know that should their health deteriorate and decline, should the passage of time mean that they are less able and fit than they once were, then the place they would want to be is in their own home. The familiarity of place is critical to the psychological and emotional health we all know to be fundamental to our wellbeing.

There is also a generally accepted recognition that one of the ways in which we can help people avoid unnecessary admission to hospital is to keep them healthy and well at home. This not only prevents avoidable hospital admissions with all the pressures that brings on the whole health and social care system but more importantly with all the risks that being in hospital for periods of time brings to the individual themselves.

Over the last few weeks and winter/spring months there has been a great deal of media and political focus on delayed discharge – that is when people are unnecessarily delayed in being discharged from hospital when they are fit for discharge. There has been equal focus and attention – and indeed resource – being allocated to ‘hospital at home’ models and innovations. All of these are to be applauded and affirmed because they adhere to the great principles of the NHS, which is to treat, care and support individuals as close to home and community as possible.

But what about preventative social care? It is all very well to develop important initiatives to get people out of hospital and to support them in their own homes when they are discharged, but it would be so much better if we prevented or at least delayed for as long as possible admission into hospital. That is where social care systems and supports when they work well are able to make such a significant contribution.

One of the really negative impacts of austerity and the increasing resource swallowed up by the acute NHS systems has been the stripping out of the preventative approach, systems and models in social care. This has been a dangerous and damaging error. The less we spend on preventative social care the more we end up spending on the acute and secondary NHS.

Preventative social care comes in many guises. It is first and foremost relationship based social care where the support worker or carer is able over time to form a meaningful relationship with the supported person. Such a depth relationship – which requires continuity of staffing and consistency of service – build not only a relationship but critically enables the worker to develop the insights, knowledge and awareness that enables him or her to be aware of changes in the behaviour, presentation and health of the supported person. Without being overly idealistic – this is what good old-fashioned relationship-based care at home used to deliver as routine. Care staff knew their clients and were the early warning systems which recognised a negative response to new medication, which questioned the benefits of multiple drugs, which enabled a person to be independent rather than nurture dependency, which reduced the harms of loneliness and isolation, which monitored incidents such as falls, memory loss and deterioration and so much more.

Such good and effective preventative social care requires many things – not least of which is a staffing cohort which are valued, rewarded appropriately for their skills, and esteemed as core professionals and colleagues by others in a primary or community acre team. Their word, judgement and awareness are heard and respected.

But it also requires that most elusive of care and clinical tools – time. The sad increase in 15-minute care packages and visits over the last few years – at a time when we were supposed to be ending them – has had a deep impact on the quality of time staff are able to spend with individuals. I defy anyone to justify that such time slots offer dignified, right-based, relationship-focussed social care. They are transactions of function rather than timeslots of compassionate care and support.

There is another element to preventative social care which is often forgotten. Prevention of negative health incidents and decline requires an individual to self-manage a long-term condition or to be at the very least aware of the factors that might impact them in a negative way. Preventative social care can encourage folks to be more proactive and knowledgeable about their health and wellbeing. I think we are missing a great public health opportunity by not enabling social care staff to be the frontline of such public education, awareness, and promotion of self-management. If they have a relationship with the supported person, it is already a door open to increased awareness and communication. Good preventative social care which utilises the contact between carer and supported person could significantly lead to increased independence and thus reduce or delay the need for care and support services.

But prevention does not just happen – it is not an accidental by-product but something which has to be designed, nurtured, and resourced. I would love to see equal resource and emphasis being placed on investment in social care especially care at home and housing support being seen as a preventative tool as equally important as the resource we allocate to getting people out of hospital or caring from them clinically in their own home. But of course, that requires whole system, holistic health and social care thinking and co-ordination rather than just attending to one part of the system.

Donald Macaskill

This blog formed part of a speech delivered at Erskine Home, Renfrewshire to celebrate the International Day of the Nurse 2023.

As many of you might know from some of my blogs and talks – I come from a family of strong Highland women!

When I was growing up there were two professions which dominated my family environment – both occupied by strong women – teaching and nursing.

One of those I want to talk about is my great aunt who had she been alive would be over 140 years old. She was ‘widowed’ in the First World War – though in truth she was never married but engaged to a young man who lost his life in the trenches but for whom she ever after wore the black of widowhood and never married.

She was an astonishingly literate and widely read woman who was a headteacher with an indomitable and quite ferocious spirit. In fact, she was quite scary! But she had wonderful stories and being a bit of a sponge, I soaked many of them up only realising their significance a lot later. She had an array of friends all over the country and indeed the world. Many of them like her were strong characters.

One of the people she occasionally talked about was someone a good 14 years younger than herself but with whom she shared a real affinity. Her name was Mairi Chisholm whom some of you may know though I suspect many of you might not – but in her day she was probably one of the most famous and photographed nurses of her generation.

Mairi Lambert Gooden Chisholm, of Chisholm (1896-1981), known as Mairi Chisholm, was an ambulance driver and first aider and then nurse on the Western Front in Belgium during the First World War.

Brought up in England but from very Highland stock, Mairi was deeply influenced by her older brother, Uailean, who owned a Royal Enfield 425cc motorcycle. She adored motorcycles and persuaded her father to buy her one which she spent days stripping down and putting back together. She was 18 years old when she met the 30-year-old Elsie Knocker, who shared the same passion for motorcycling, and they became good friends

At the outbreak of the First World War, Mairi and Elsie travelled to London on motorcycles to offer their services to the War Office. It was when working as dispatch drivers that they were spotted by Dr Hector Munro, a Scottish doctor and founder of the volunteer Flying Ambulance Corps (FAC), who invited them to join him on the front in Belgium from September 1914.

Mairi Chisholm and Elsie Knocker, became known as the ‘women or angels of Pervyse’ and together they saved the lives of thousands of soldiers and won numerous medals for bravery.

What marked them out as different was that they soon came to the conclusion that they could save more lives by treating the wounded directly on the front lines rather than transporting casualties to hospitals. They set up one hundred yards from the trenches and they called their place “Poste de Secours Anglais” (“British First Aid Post”). They spent the next three and a half years tending to the wounded.

It was an astonishingly hard time, not least in that they had to raise their own funds for their new station. Then in March 1918, they were both badly affected by a bombing raid and gas attacks on their field hospital and were invalided home. Chisholm was able to return briefly to Pervijze, before being gassed again; she was only 22 years old.

She went on to live a colourful and fulfilling life and after many more adventures died in Argyll in 1981.

Back to my great aunt. She recalled conversations she had with Mairi about what it was like to nurse and what she learned from the experience in the First World War. There are several things which both Mairi and Elsie showed which I think on this International Day of the Nurse still are apposite and are the essence of nursing.

The first is that at the start of their work Mairi and Elsie were not nurses – they had received the most basic of training but over the years developed real experience and skill so much so that they were feted by the media and others as exemplars of what nursing should be both during the war and for the decade after.

But my aunt always pointed out that Mairi consistently said that what mattered most was not the uniform you wore, the unit you belonged to, but the skills and talents you developed and displayed.

There is a lot of necessary debate about what should constitute the core skills and competencies of modern-day nursing. Indeed, I have written and commented about how important that debate is, not least when we are faced with the shortage of registered nurses working in social care. It is fundamental that we know and agree what for instance are the boundaries of role and competence between a nurse and say a senior carer.

But what was intrinsically true for Mairi was that regardless of training or title, what ultimately mattered was the ability to use skills in the service of the individual rather than the validation of personal nursing identity. What was critical was the whole team and group effort rather than the elevation of one role, however important, over another.

And a care home is an exemplar par excellence of that – it is only when acting in concert and together that we ensure the individual resident receives the best possible care and support that they deserve.

The second thing I remember being told about Mairi was that she had a passionate belief that treatment and care must go to the person and not the other way around. Now that’s a relatively easy statement to make – in fact it is the ethos of the developing concepts and delivery of hospital at home programmes and approaches – we have many of us known for long that the community should be the cradle of clinical care and not the acute hospital alone.

For Mairi that belief and conviction was one that was immensely dangerous and harrowing. It meant that quite literally she was under fire all the time – a reality that caused damage to her health which would result in a life-long impact both physically and psychologically.

But in truth that is what is still true today – we go to where people need us and when they require that support. For Mairi nursing was about being useful where you were needed – nursing was in the place and space it was necessary to be.

The third thing I heard from my aunt was that nursing and care in general was first and foremost about relationship. In an emergency war situation, you might think there was a risk that with real life and death pressures that care and support became transactional, perhaps even mechanistic and automatic.

Far from it- in her writings and in her conversation Mairi Chisholm emphasised how important it was that we see care and support, whether given by a nurse or a carer as something which if it was to be effective had to be grounded in the formation of a close and meaningful personal relationship with the person being supported and cared for.

That insight seems almost a taken for granted view of care and support today but at the time it was something that was not all that commonplace. The citations for the many medals they received demonstrated the personal care and compassion that the ‘Angels of Pervyse’ displayed.

Nursing and care were for them and must be for us today about making people feel that they mattered, that you listened to them and heard what they were wanting and needing.

And perhaps finally that is no more than true in a context of nursing in the face of death.

Those of us in this room who have been granted the privilege to be present with someone as they die; to nurture their leaving of life in a way that gives them comfort, that reduces fear and offers solace; those who have felt the pulse of life leave a body, will be well accustomed to the special character of those times, and to their continual hardness.

I suspect the majority of us will not like Mairi and Elsie have had to deal with trauma quite as severe, but each death brings its own special moment of memory for those left behind, and the care and compassion, the practical assurance and skill that is shown at such times to a care home resident are our gift to a family starting the steps of their grief journey.

I could go on about Mairi Chisholm and the memories of my great aunt a lot – but those key aspects I feel have something to say to us nearly 120 years later.

They are that nursing and care and support have to do with recognising the intrinsic value of the person who occupies a nursing role and the critical role of being part of a team; they are that for care and support to be effective nursing and care needs to go to where the person is and to their space and place; that relationship which discovers the person is at the heart of nursing and lastly that it is the accompanying of another in the last hours and moments of their living that the humanity of our roles comes to the fore.

Social care nursing and care are many things – it is a discipline and profession which has been so grossly under-appreciated and valued – and which slowly is coming out of the shadows to shout and celebrate its unique complementary offer to the whole of care support and nursing.

Social care nursing is in some senses – a bit like Mairi Chisholm’s attempts to describe her role – beyond description – but its dynamic is the presence of familiarity in the midst of uncertainty; the valuing of individuality ; the creation of space that heals and holds; the ability to listen beyond and below what is said; the instinctive knowingness which comes from presence which goes beyond the physical.

But in the end of the day whether for a nurse, or a carer, or a domestic member of staff it all boils down to the person inside that uniform.

Mairi Chisholm, challenged expectation and displayed a humanity of compassion and courageous care to the end of her days; she became a pin up of the media of her time ; but she sought not fame or fortune; but to make a difference and in everything you do you can be assured that that is what you do every day – and for that we thank you. You truly make a difference.

Biographical Details taken from:  Our Records: Mairi Chisholm (1896-1981), ambulance driver and first aider in the First World War | ScotlandsPeople

Donald Macaskill