Re-imagining care homes – time to explore.

The following talk was in part delivered at the close of the Scottish Care Care Home Conference held in Glasgow yesterday.

 I don’t get much time for reading these days so when I do something needs to capture and hold me – and one book recently has done just that – Sir Geoff Mulgan is Professor of Collective Intelligence, Public Policy and Social Innovation at University College London. He used to be chief executive of Nesta and held government roles including as Downing Street’s head of policy in the early noughties. He’s written a book called ‘Another World is Possible: how to reignite social and political imagination.’ I’d thoroughly recommend it as it is a book brim-full of ideas and insights, no little challenge and a lot of provocation.

Its main argument is that as societies and the world face the challenges of living in the light of the pandemic and the ‘slow calamity of climate change, we also face a third, less visible emergency: ‘a crisis of imagination.’

Mulgan argues that especially the young struggle to imagine a world better than the one we live in now and that perhaps they are the first generation so to believe – the first generation which is less positive about the future we are creating and leaving for our inheritors. Too many are resigned to fatalism or at most tinkering on the edges of real change and transformation. This crisis of imagination is crippling us and we need to discover ways to reimagine the future to reimagine better and to visualise how we are going to arrive and get there.

I don’t know about you but I certainly want the children of my living and the community of my belonging to be living in a world better than it is now and I still with Mulgan believe a better world is possible.

And I know that’s hard – it’s risky to dream and visualise change and difference and not be accused of escapism and utopian folly – but I think that’s what we have to do even after a day in which we have not exactly avoided or not heard the challenges facing the care home sector in Scotland.

I want to use some of what Mulgan says to spend a bit of time at the end of our day reflecting on the future of care homes. I want the reflection to be practical in nature, but I also want to challenge both myself and ourselves. I am starting from the premise – that we urgently need to re-imagine the future of care homes and aged care in general – in part because I do not think we can stand still, that what we offer now will not be fit for purpose in fifteen or twenty years, and that if the sector and its leadership does not do the work of re-imagining tomorrow’s care and support  – along with those who use supports and their advocates and those who are likely to be users of aged care in the future  – then the re-design will be undertaken by the misinformed, biased and partisan – no doubt accusations which will be directed towards myself. But I’m also convinced that re-imagining always is an activity shared with others never a solitary pursuit if real change is desired.

So why is imagination so important? Mulgan explores this in great depth using insights from Socrates to Star Wars and with him I believe that ‘Society now and in the future depends on imagination.’

He rightly critiques the fact that there is a real dearth of imagination and a poverty of ideas in our society… and I think that accusation can be amplified when we think of the world of social care – and I will be honest from what I have seen thus far from the ideas of the National Care Service – although there is a lot of good stuff, its view of the imagined possible future is predictable, pedestrian and a re-shaping of the known into a familiar future not one that will outlive its designers. And lazy re-imagining is dangerous and inexcusable – because and this is selfish – I do not want a future world of social care support to be the fruit of compromise and affordability, of lazy design and casual engagement – I want it to be a horizon which draws me in and which opens up a new world for me.

Imagination is a powerful force and tool if used well. For something to be it has to become real and imagining something births that reality. Ideas do not come from nothing, new systems, and ways of relating originate somewhere with someone or they remain forever locked in our heads.

Imagining the future of care homes is not about cloud cuckoo land but recognising that the fruit of tomorrow is already growing in the soil of our present experience.

Part of what I think the residential care sector has to do is to develop what Mulgan calls the ‘adjacent possible’ – the nearby options which are the alternatives to present arrangements – but have a spark of the familiar. But I also think we have to go much further than just tweaking or light changes – we have to be much more adventurous and explorative. We have to develop a collective of care imaginaries – people who have the skill and foresight to imagine a better future and a different way of being and doing aged care.

Social care in Scotland badly needs dreamers and people who can see beyond the limited vision of the now. That’s why I have looked with real interest at the HIVE collective. But I hope you will excuse me because I am going to try and picture a different future –to try to expand what Mulgan calls the ‘possibility space’ ; to backcast into the future.

In visualising that future I want to plant certain seeds in the present and you can decide if they grow and flourish or if they deserve to shrivel in the earth.

The first is that we have to urgently re-imagine age:

I do hope that at some point today you have had the chance to drop by the stall staffed by colleagues from the University of Stirling and elsewhere and have learned more about the project Reimagining the Future of Older Age. They have done some brilliant work including producing a gorgeous film by Ray Bird. The project is about how we think about the future as we age and as we become older; does the future matter more or does it matter less? It challenges the dominant stereotype and cultural narrative which presents older age as nothing to do with the future – the belief that the future belongs to the young.

Dr Valerie Wright now of Glasgow University reflects that as we grow up we always ask young people ‘What do you want to be when you grow up?’  but no- one ever asks older people what do you want to do in the future? What do you want to do when you get older? Who do you want to be? And how very true she is.

A reimagining of age is necessary to challenge the inadequacy of those narratives and societal biases. As I have consistently and often said I have personally witnessed first-hand, lives transformed and changed, as in the last months, days and moments of life a reconciliation has been nurtured, a discovery made, a new creative contribution shared, and a new loving started.  The future has no use by date.

And let’s be honest the world of social care and aged care is too often dominated by a narrative which accepts the bias against contribution and capacity of older age.

For instance, we have rightly used reminiscence – a looking back – as a mechanism and a means to ease the distress of those with neurological conditions such as dementia – but I increasingly wonder whether the dominance of reminiscence approaches is misplaced and that we are losing real neurological benefit by not adopting a more futuristic approach to dementia care and support and to older aged care in general.

Reimagining age whether in care home or community is a fundamental first step to the reimagining of a future of contribution and new discovery.

The second seed which I think the world of aged care needs is to re-imagine the very essence and nature of collective living, of being in community in older age with one others.

It is inescapable – and this is true of the world over – that we must ask a fundamental question as to whether or not congregated or collective or group living remains an appropriate modern form of being in community with others.

Or being blunt do we just do it for those who are too old, too frail, too poor, because it is the cheapest way for a society to hold to its moral and ethical duties of care? Hard words but unless we can answer them in an affirmative way which says no – that collective living in older age can be life-changing, life affirming and life enhancing – then we are deceiving no-one.

Now my personal premise is that I really do believe that the future – to say nothing of the present – is about us living by choice not by cost – in community alongside others.

Some would say congregated living is always wrong – never acceptable – and Twitter is alive with a narrative which equates care homes as removers of rights, limiters of choice and control, ‘prisons’ of individuality. That critique has to be answered honestly.

But personally, I believe there is a future for collective and shared living and one of the reasons is that it is better than isolated loneliness. It will not be long before the majority of people in Scotland over the age of 65 will be living in single person households – and we have already witnessed a saddening growth in isolation, loneliness and mental distress amongst those who are alone – so it is not unreasonable to suggest that increasingly there will be a growing number of people who choose to live alongside others, and at a stage of  life when they have control and capacity – that shared collective living becomes something that is desirable and beneficial.

But just as I am convinced that collective and shared living has a place in the future of aged care – so I am equally convinced that a radical re-design of the way we deliver care and support in a shared space is very necessary.

There is a narrative which says that shared living is about creating a home from home; that care homes are people’s homes first and foremost. Inevitably there is a counter critique not least as a result of pandemic response and behaviours, that says that care homes have failed in being a person’s home. So the sector has to honestly ask, in replicating a home from home how are we doing?

Are our care homes places where people can live and love, rest and be loved, grow and be fulfilled, discover and change – or are they rather places where folks work, people are checked and viewed, monitored and evaluated? Are they places where we obsess about risk or let the mess flow, are they tidy or unkempt, disease free or life affirming?

We use home not to limit or imprison us but as a place to be ourselves, to be fed and renewed, to rest and relax, to entertain and be entertained, to sleep and restore, to be secure and be comfortable, to hide and be private. Are our care homes such a space and place?

For me a home is a place to make memories – what are the memories made in our care homes? Are they life enhancing or life limiting?

If we answer that care homes are not a home from home, then we have to ask honestly can we change that to a yes?

My third seed is that for me part of the re-imagining of aged care must surely be about build and design. Imagine a world will you where you all live in exactly the same type of house – everything is the same – no variety and no distinctiveness – every room measures the same, the layout identical, the windows are where they are – the mundanity of the predictable rules. But your individuality is allowed up to a point – you can decorate the space as you want – you can even bring some of your own things – providing they are of suitable material as to prevent infectious spread and conflagration. Not that much of a caricature in case I’m accused of it

The future has to be not so much about the architecture of design and more about the imagination of space. I think we need a radical redesign of space and place so that we allow both architectural and design freedom -collective living in space needs a revolution – or we will continue to ghettoise older age – at its worst in places separate from community by geography and cost or separated from connection even in the midst of busyness. Aged care beyond four walls does not just happen by accident it has to be purposefully designed and built.

There are emerging examples of such creativity like the ‘What we Share’ models in Stavanger Norway; Berlin’s ‘baugruppen’; Lange Enk in Denmark or Kraftwerk 2 in Switzerland.

We have a chance to capture the design spirit of the age. The idea of ‘fifteen-minute cities’ – sometimes known as 20-minute neighbourhoods – probably needs little introduction. Strongly associated with the Paris professor Carlos Moreno, and the mayor Anne Hidalgo, it has gained extra energy from the pandemic and the changes in our living in community. Its basic premise is that all our daily necessities can be accomplished by either walking or cycling from our homes. It shrinks the whole concept of what local means to the touching – or walking distance of our neighbourhood. It is closely linked to the concept which is becoming hugely popular of ‘ageing in place’ which is “the ability to live in one’s own home and community safely, independently, and comfortably, regardless of age, income, or ability level.” Ageing in place has something to say to the future of aged care in residential and nursing shared communities.

My last seed is that we radically need to re-imagine the nature of scrutiny, inspection and oversight in aged care. Of course, both families and residents, and wider society needs a sense of assurance about the quality and humanity of care – but increasingly I feel we have the balance all wrong. A care home resident is more closely observed, monitored, and watched than your average penguin at Edinburgh Zoo. The human right to privacy, to dignity alone, to the joy of absence, the hiddenness of living – all are lost when we turn our aged care settings into goldfish bowls. The individuality and uniqueness of the person, the desire to take risks and make mistakes, to fall in your failing and rise in your discovery are put aside if we adopt measures that limit self-expression, individuality, and freedom.

The perverse irony is that all our standards and statements talk about systems being person-centred but leave no room for care support to be person led by resident and family. At the very least we need a radical balancing of risk in aged care regulation. The constant current behaviour and presumption of the right to intrude on the part of outside agencies is offensive and unacceptable.

I could go on but for me this is a conversation not a soliloquy – the future of aged care in Scotland – of collective shared living is too important to leave to accident or happenstance – it needs a work of imaginative discovery and exploration.

I love old maps because at their best they are not about helping you find your way, but they tell you the story of a community or nation at a particular time. None more so than ancient medieval maps. On many of these maps at the edge you can sometimes see a picture of a wild beast and the words ‘ Here be dragons…’ – that was for all the places which were unknown and yet to be discovered.

Explorers use the knowledge they have to try and test the waters of the future – they venture into the unknown, but they are not just dreamers searching for utopia – because they use the skills and instruments of their known reality to create a different tomorrow.

Reimagining the future of aged care is about travelling beyond the known into a new world of discovery – it’s about re-designing with others, a future we want to achieve – it is a world where older age still grows And flourishes and changes and contradicts; it is a space and place where conformity to design is replaced by the adventure of personal control and choice; it is an experience of self-freedom rather than external monitoring; put simply it has to be a world which we would be proud for our children and our grandchildren to inherit.


Donald Macaskill