Adult care homes - vitamin D supplementation guidance: business and regulatory impact assessment

2. Purpose and intended effect

To provide guidance materials which support care homes to:

• adopt existing recommendations around vitamin D supplementation for people living in adult care home as per 2016 Scientific Advisory Committee on Nutrition (SACN) advice^[1] and Scottish Government vitamin D policy^[2]
• hold person-centred conversations with residents and their families about vitamin D supplementation.

2.1 Background

Vitamin D plays a crucial role in regulating calcium and phosphate levels which are crucial for bone and muscle health. According to the SACN there is considerable evidence on the benefits of vitamin D on musculoskeletal health outcomes such as decreased risk of osteomalacia, improvement of muscle strength and function and reduction in fall risk for those over 50 years old.(SACN, 2016). Vitamin D is obtained from dietary sources such as food and supplements or produced in the skin following ultraviolet B (UVB) radiation (Holick, 1994)^[3].

The exposure to UVB depends on factors such as latitude, season, time of the day. In Scotland, the levels of vitamin D are affected by the limitation of sunlight due to lack of exposure from October to the end of March (SACN, 2016). Concentrations below 25 nmol/L of vitamin D (25(OH)D, which is a biomarker of vitamin D status, this level is correlated with an increased risk of poor musculoskeletal health (SACN, 2016). Such concentration is difficult to achieve by certain groups in the population due to lack of exposure to sunshine. Among those are frail and institutionalised people, including those living in care homes (SACN, 2016). Therefore SACN has, since 2016, recommended an intake of 10 μg (400 IU) throughout the year in order to cover those groups at risk of having vitamin D below the recommended concentration levels (SACN, 2016) . During the Covid-19 pandemic individuals who were shielding in Scotland, including those living in care homes, were offered vitamin D supplementation for a period of 4 months from December 2020. However, only an average of 35% of individuals over 65 years old took the vitamin D supplementation (Campbell, 2022; NHS Education for Scotland, 2021) [4].

Following the SCAN recommendation in 2016, the previous Chief Medical Officer (CMO) wrote to health professionals and other agencies in 2017 to highlight the recommendations including for older people less able to go outside. This recommendation is referred to in Care Inspectorate’s Eating and Drinking Well in Care: Good Practice Guidance for Older People | Care Inspectorate Hub.

In January 2021, the CMO wrote to care homes recommending that the provision of vitamin D supplementation should be considered for all care home residents taking account of their needs and preferences. In response to feedback from the sector around the need for guidance on implementation, CMO and the Chief Pharmaceutical Officer (CPO) asked officials to establish a SLWG to make recommendations based on current evidence on whether care home residents should be offered and given access to vitamin D supplementation and, if so, how this would be achieved consistently.

The SLWG group, chaired by a CMO Professional Adviser for Ageing and Health, and Head of Effective Prescribing and Therapeutics, comprised a range of stakeholders, including care home representatives, Care Inspectorate, pharmacists, consultant dietitian, senior nurse and clinical lecturer in geriatric medicine. includes SG policy officials, NHS colleagues, and representatives of Care Home Providers.

SLWG made the following recommendations:

• That we adhere to the recommendations made by SACN and that all residents should have an opportunity to receive vitamin D supplementation.
• Supplementation of vitamin D is considered in a person-centred way, where decisions are made on an individual basis, taking into account the residents’ personal choice, needs and circumstances.
• We should try to achieve this without over-medicalising something that is a nutritional supplement rather than a medicine or drug.
• Ahead of a national rollout, there is a pilot to test SLWG developed vitamin D resource materials, access, uptake and recording.

NHS Ayrshire and Arran (NHS A&A) agreed to run the pilot which began in October 2022, initially involving four homes with funding from SG for the supplements. A further two homes participated following an extension of the pilot in January 2023. Scottish Government funded NHS A&A to purchase vitamin D supplements for the care homes. The findings are summarised in Annex B but essentially the evaluation demonstrated:

• a positive overall experience of offering vitamin D to eligible residents, with 47% of residents in the pilot care homes accessing the supplements.
• main reasons for not participating: residents already taking a prescribed dose of vitamin D (29.7%), other medical conditions preventing this (16.6%), residents decided not to take part (6.2%) and residents taking a non-prescribed dose of vitamin D (0.6%).
• that it was possible for care home staff to administer the vitamin D supplements in a ‘non-medical’ way through the use of checklist and supporting guidance.
• the need for minor changes to the guidance materials to improve clarity.
• a willingness of participating care homes to continue to provide vitamin D supplementation for residents.
• the need for care homes, GPs and local pharmacies to be fully informed about the process to support implementation.

Based on the evaluation findings, the SLWG recommended that we implement their recommendations and that updated guidance materials are issued to care homes to enable eligible care home residents are offered vitamin D supplementation. The SLWG noted however the burden on care homes in terms of the time to identify which residents were eligible for the supplements and to offer them in a person-centred way, and the time to administer and record when the supplements were taken.

2.2 Rationale for Government intervention

This is not a new policy. Scottish Government policy on vitamin D supplementation including for people in care homes has, for some years reflected 2016 SCAN recommendations which has been communicated by previous CMOs and reflected in Care Inspectorate eating well guidance. However during our engagement with stakeholders, it became clear that to support wider adoption of such a recommendation, further guidance should be developed for care homes. Many care home residents are already prescribed vitamin D for deficiency (around 30%) which is a much higher dose than that contained within a supplement.

The purpose of the work therefore has been to work with stakeholders to develop appropriate guidance for care homes and those that support care homes to enable adoption of existing Scottish Government / SACN recommendations/ policy.

Taken together the government intervention will be to:

• issue guidance for the sector about adopting existing advice that eligible people living in adult care home should be offered the opportunity to receive vitamin D supplementation, taking into account their personal choice, needs and circumstances.
• provide guidance materials for care homes and those that work with the sector to support person-centred conversations with residents and their families.

National Outcomes

This contributes to national performance framework outcome that:

• people are healthy and active.

2.3 Sectors and groups affected

The proposal to issue guidance on vitamin D for the care home sector is intended to apply to adult care homes registered with the Care Inspectorate. The care home census shows that as at 31 March there were 1,051 care homes for adults and 33,352 residents aged 18 years and over in care homes in Scotland^[5]. The vast majority of people living in care homes are older people (Residents in care homes for older people account for 92% of residents in all care homes) many of whom will have disabilities such as dementia (approximately 64%). Many will be unable to generate vitamin D from going outside either because they can’t leave the home or they will not be outside for long enough. This is also likely to apply to people living in care homes who are under 65 years. Females account for approximately 70% of long stay residents in care homes for older people and predominate especially in the older age groups.

Most care homes for adults are delivered by the private sector (around (64%) but the voluntary and not-for-profit sector (23%) and local authorities (13%) also play an important role.

In summary the following people are likely to be affected by the proposals:

• Adults living in care homes and their representatives
• Care home staff
• Organisations and professions that support care homes eg pharmacists, GPs community nurses, Care Inspectorate.