Scotland needs accessible and deliverable social care

By Katherine Crawford, Chief Executive Officer

‘Fix social care’ and ‘care reform’ are familiar refrains to many of us, but what do they really mean to most people in Scotland? Unless you’re one of around 175,000 people receiving or waiting for a care package or one of up to 800,000 unpaid carers supporting someone in need, it’s likely the phrase means very little. But it should be important because the truth is that many, if not most, of us will need social care at some point in our lives. 

I’ve worked in the third sector for over 20 years now. The rhetoric around health and social care reform trips off my tongue. But if you work as a carer, an adviser, care navigator/ advocate, or are a family member facing the intricacies of trying to support or access a meaningful care package, that rhetoric becomes fairly meaningless. A person’s care needs are often profound and will be immediate. Every day’s delay risks further depleting someone’s quality of life. 

As the Scottish charity for older people, Age Scotland is all too aware of how great the need for an accessible and deliverable social care system is. Every day older people, their families or carers download information guides on social care provision. Our helpline handles hundreds of calls from people desperately trying to find their way through a tangled system. At a time when things have reached breaking point, support is urgently needed and the callers are often plain exhausted. 

Problems in the social care sector don’t only impact the older person in need but also those who find themselves thrust without warning into the role of unpaid carer. This quote from a member of Age Scotland’s Human Rights Working group, who is also an unpaid carer, illustrates the need for radical change:  

“The key is not just adding services but transforming the system so that recognising and supporting unpaid carers becomes a default not an afterthought.”

There is no shying away from the fact that unpaid carers, who might not even recognise themselves as carers, provide countless hours of support, day and night. That comes at a high personal cost. Carers Scotland’s 2025 ‘Cost of Caring Report’ found: 

• 30% of unpaid carers said they had bad or very bad physical health
• 34% reported having bad or very bad mental health  

At Age Scotland we often hear from people grateful for the most basic levels of support. They accept care packages which only attend to some of their needs and don’t like to ask for more. This reflects the position we’re in. People accept that the system can’t fulfil all their needs and appreciate any support offered. Often they don’t have the energy or knowledge to challenge the vastly complex system. It certainly isn’t easy.  

Another stumbling block is geography. Comparing data and insight from around Scotland’s local authorities quickly throws up a substantive imbalance in how care is delivered area to area, even town to town.  Workforce challenges are exacerbated by the country’s physical geography and Scottish society’s ongoing struggle with health inequalities in areas of greatest socio-economic deprivation.  

 When it comes to social care the inconsistencies in accessibility and delivery mean people don’t know what they can expect from it. It’s harder to put into words than, say, our expectations of the NHS. We understand waiting lists, recognise a decent hospital infrastructure, know what we expect from an appointment with a dentist or doctor and if the reality doesn’t meet our expectations we can challenge it more effectively. That understanding also keeps the NHS in the public spotlight and makes it a consistent political priority. 

Compared to the transparency in the NHS, social care lurks in the shadows and, as we know only too well, it is not a political priority. Yes, it’s talked about but quickly slides to the bottom of the pile when the spotlight moves elsewhere.  

But why isn’t social care being addressed more urgently? Those working within the system have been expressing frustration for years. Carers themselves want to provide high-quality social care. Local authorities, care organisations, some politicians and charities like ours have repeatedly flagged the problems that are crippling the sector. So what is stopping decision makers getting round a table to come up with a deliverable plan to fix social care? 

My first role in the third sector was as a support worker, advocating for individual’s rights. That was way back in 2004. Even then, my heart went out to the individuals and to the beleaguered social services staff who knew that they didn’t have the capacity to provide the service that was needed. Nobody can say the current system fell apart overnight – or even in the lifetime of any particular government.  

In 2024 I chaired a national conference on social care and was struck by the fact that ministers, care providers, individual activists, charities and people in receipt of care each had a shocking case study to share. In some cases a lack of funding and system complexity came together to deliver appalling standards of care. In others no care at all. There is no doubt everyone sharing the story felt true compassion and frustration. Yet, despite compelling evidence, our transformational reform agenda has stalled. 

The failure to garner enough support to deliver the National Care Service Bill, heralded as the big bold move to put social care on an equal footing with healthcare, leaves a sour taste. But we can’t let that derail the entire reform agenda. We need to be confident that we are holding true to our values of delivering equality and human rights. At Age Scotland we fundamentally believe that older people must be at the centre of thinking, planning and delivery. To succeed, a strategy to fix social care must come back to those fundamental principles around human rights and strategy creators must keep listening to those voices. 

Looking again to the NHS, there have been great pieces of innovation in NHS services, such as the valuable Hospital at Home initiative, but it takes time to evaluate and embed. The Hospital at Home pilot in South Lanarkshire began in 2011 and it has taken 14 years to roll it out at scale across the country. To be blunt, the current social care system can’t wait 14 years for improvement. The older people in need can’t wait 14 weeks, and yet all too often they have no choice. 

The urgency to fixing social care doesn’t appear to be widely recognised. And that extends to our own actions when it comes to thinking about our own future social care requirements. All of us should be prepared for a time when we may no longer have capacity. Scotland’s Power of Attorney ( PoA) legislation enables people to plan in advance, delegating authority to people that they trust through a system that builds in protections. 

However, the PoA application process is complicated and can be expensive for many. It’s estimated that 83% of adults in Scotland have a welfare PoA but I would argue strongly that every single one of us should have both welfare and financial PoAs from the moment we reach adulthood. Evidence now shows that a lack of PoAs is causing issues around delayed discharge from hospital with 21% of delays being as a result of AWI (Adults with Incapacity) reasons in 2024/25. This is almost 150,000 people who are potentially unable to articulate their wishes around social care too.  

There are so many damaging consequences to struggling on with a broken social care system, for older people, those living with dementia, people with long term health conditions and many others. As time goes by with no sign of improvement, the less faith people have and human misery is compounded.

I don’t profess to have a magical solution to what feels like an intractable problem, but in a bid to advance the reform agenda, here’s what we would like to see happen soon after the Scottish parliamentary election in May. We want the leaders of the political parties at Holyrood to get together and agree that social care must be a collective focus. We want them to plot out an agreed framework for what needs reform and, broadly, how that will be achieved. Stop hand wringing and work together on a bold plan in the best interests of the country. 

Maybe once the party political bickering is set aside, leaders can sit down and create a truly transformational outcome for social care. Put human rights, dignity and personal choice at the heart of a reinvigorated and fully integrated social care system for older people now and for generations to come. It’s a big ask but from my standpoint, it’s the only option if we’re ever going to make progress.    

This piece was orginally written for Enlighten's NHS 2048 series.