What price dignity? The state of social care in Scotland today.

This week’s blog is partly based on a talk given at the Care Roadshow, Hampden Park on Tuesday 18th April.

Dignity has always been an important concept and word for me. In part because having worked in the equality and human rights field it is one of the bedrocks upon which our modern ethical, moral, and legal frameworks have been built. Indeed, the opening words of the first Article of the United Nations Declaration of Human Rights declares:

All human beings are born free and equal in dignity and rights.

There are essays and books, PhDs and poems, written about what dignity means both legally, philosophically and in practice. Indeed, there is an important current debate about whether human rights as a whole and dignity specifically are indeed inherent and part of our DNA as human beings or if they only really become meaningful with our belonging to a State as citizens which enables their fulfilment and realisation. In truth we know that simply saying something does not make it true. Without the power of a State our rights are meaningless – and indeed as too many of us know even with the so-called validation of a Government our human rights can be but paper aspirations.

But I think there is something different about dignity – my belonging to a community may bestow me with human rights but if I lose citizenship or association for whatever reason – I do not I would contend lose my right to be treated with dignity.

Now however fascinating the philosophical debates might be I am not going to go there. I am going to assume that part of our humanity is our human dignity and the right to have that dignity upheld, protected, furthered and nurtured.

But what is this dignity? What does dignity mean to me and perhaps more importantly what should it mean in the context of social care and support.

The dictionary is clear and emphatic. Dignity is defined as

‘the state or quality of being worthy of honour or respect.’

And then there are a sample of other definitions. In fact, despite its centrality in the delivery of person-led social care there is no consistent universally agreed definition. I haven’t got a problem with that because the very nature of dignity and rights, should be about the dynamic of undefinable human relationships meaning that in different contexts, for diverse peoples, and in multiple dynamics dignity will mean different things. It truly is in the perspective of the beholder and the community in which they are living and relating. So it is that one group the Social Care Institute for Excellence (SCIE) states:

“Dignity in care means providing care that supports the self-respect of the person, recognising their capacities and ambitions, and does nothing to undermine it.

One homecare organisation, GoodOaks Homecare says:

“Giving people space and time to do things at their own pace. Giving people a choice over their care options and asking their preferences for care. Giving people autonomy over their lives – from the choice of what to wear, to what to eat and what to do. Making sure someone is not in pain.”

There are lots of common threads in most of the definitions you will come across– and I think they are each of them true up to a point. A few years ago I did an exercise in which I asked a group of participants two questions: What makes you feel that you belong, that you matter? Then I asked them if someone is treating you with dignity what does it look or feel like. The two lists were remarkably similar and both suggest a dynamic positivism to what dignity meant – it wasn’t something to be taken off a shelf – it was personal, active, participative and owned.

There are I think some key characteristics of dignity which appear in all the definitions and in what people themselves say. The group I worked with both described what it felt like and what it left them with a sense of:

  • I was heard and not just listened to.
  • They gave me time to talk and tell.
  • They treated me as an individual not as another case.
  • They spent time and got to know me.
  • They came up with really practical steps.
  • They believed what I was saying.
  • Nothing was too much for them.
  • I felt as if I had known them for years.
  • They allowed me to make mistakes.

So, dignity in care – in social care – is a really life-affirming experience that places the person not in the centre but in control – it is a dynamic of relationship which results in an altered experience for both supported person and carer.

Over the years I have increasingly come to know that dignity is at the heart of social care and support.  But dignity does not just happen; dignified and equal treatment isn’t an accidental occurrence but a determined action. Dignity has a price and a cost, and it is something that demands prioritisation, planning and focus for it to become the lived experience and encountered reality of citizens. The question therefore has to be asked, and continually articulated, is whether or not in contemporary Scotland the way in which social care and support is delivered meets the dignity standards – and whether given those come with a cost attached we have as a society been and are prepared to pay the price for dignity?

Three brief reflections to get a sense of the price of dignity today.

Actual delivery and value.

I have often commented in the weeks that have preceded this blog that I fear there is a lack of adequate appreciation of the value and contribution of social care support. One reason is that we continue to use the perspective of the NHS and clinical care as the means by which we assess and articulate the value of social care. That is a fatal error because it fails to recognise the potential of social care and its distinctiveness. Perhaps one of the reasons that integration has so often failed in some parts of Scotland is that key stakeholders have failed to understand the contribution, voice and distinctiveness of those who are not part of their world – be it acute/secondary NHS or social care.

For me you cannot work alongside another unless you understand or at least attempt to know their language, their contribution, skills and assets. Social care and support is about enabling independence, choice and control, autonomy and voice. Also, in no small manner the social is what really matters here – it is not just care or support on their own it is social care -connection, relatedness, community, citizenship – all matter. Coincidentally the minds behind the Social Work (Scotland) Act of 1968 were of similar orientation, rooting a communitarian focussed idea of the social at the heart of care support. Social care is not solely about supporting an individual it is about supporting their connectedness to citizenship and their ownership of place in relation to others.

I do not think anyone can understand modern social care and support without also being aware of the civil rights context most especially of the disability rights movement in the 1960s through to the 1990s.  Whenever I hear commentators say we should return to health running everything or turn everything over to the NHS I quake – for years people literally fought to get out of the clutches of the healthcare system, to escape a health oriented clinical model and approach to disability, lifelong conditions, and older age; to shut down the institutions and asylums, to move people out of geriatric wards and units.

The last thing we need is a return to a health-oriented approach to living independently. Social care is not health care. Dignity is at risk if we fail to protect the distinctiveness of social care. It is a price not worth paying even if it seems an illusory answer.


In his first policy announcement to the Scottish Parliament on Tuesday last the former Cabinet Secretary for Health and Social Care and now First Minister Humza Yousaf intimated his desire to move towards paying frontline social care staff (though specifically he only mentioned staff in adult services) the £12 an hour which organisations like my own have been campaigning as the starting point for a just, equitable pay award. There was no timetable although I am led to believe that this is being urgently developed. Dependent upon the illusive timetable this is a step in the right direction. Whether it is in time to rescue the faltering and disintegrating social care sector needs yet to be determined. Sadly, in the last few weeks, as NHS colleagues are being rewarded over 19% more for doing the same work of care support compared to their social care colleagues, there has been a growing number opting to leave the social care sector, leaving us even more critically unstable and at risk. The failure to properly value All social care staff in the same measure as colleagues in the NHS has been a massive politically opportunistic error. It will unless urgently remedied fracture perhaps irreparably the social care and health cohesion of our communities. What is the price of dignity for our social care staff? Because at this juncture of time it would appear it is one that our political leadership is either very slow to pay or worse is simply not willing to pay. Even if we were to start paying workers £12 an hour tomorrow there would still be an unjustifiable gap of unequal treatment.

Lack of focus on those who require social care especially older people and their carers.

Lastly what of those who are the folks who receive social care and support, who use our care homes and are supported at home, our day services and opportunities, our housing support and sheltered accommodation. What of the tens of thousands of family and unpaid carers who have borne the burden of our community for so so long with but passing regard and recognition, and precious little support? This has been an especially hard winter and we are by no means out of its throes yet. Too many have sat in silenced hunger and in crippling cold for fear of debt and impoverishment. Too many have felt the dignity of compassion absent from their living. The price of dignity has been found to be not worth paying in so many ways not least as local authorities have chosen to make swingeing cuts to community-based services in order to balance their budgets, and I fear disproportionately these have impacted the older citizen in many communities.

Faced with what has been for so many perhaps the hardest winter to live as an older person in Scotland in recent times, it was unbelievable to witness the failure of our new Government to continue to support a distinctive Government post of Minister for Older People. Some have questioned the value of the role, but I would suggest that regardless of the postholder that having someone at the table of decision-making who ‘should’ be advocating for older persons is critical. That is one reason I and others have enthusiastically supported the campaign launched by Age Scotland.

What is the price of dignity? From eligibility criteria which are so high you need to be close to death to the failure to recognise the distinctive and unique mental health challenges faced by older people; from budget cuts at the heart of older person services and a lack of prioritising of older person issues – it would appear a price again too high to pay.

The Portuguese Nobel laureate and writer José Saramago once opined that:

“Dignity has no price, when someone starts making small concessions, in the end, life loses all meaning.”

I wonder if in terms of social care and support in Scotland in regard to our valuing of the sector and what it offers and is; the valuing of our workforce, and the valuing of older persons in general, whether we have long since stopped paying the price of dignity?

Donald Macaskill

Last Updated on 23rd April 2023 by donald.macaskill