Vitamin D in adult care homes - Equality Impact Assessment results

Please find the link to the full guidance here: Vitamin D in care homes | Care Inspectorate Hub.

Title of Policy:

Guidance to support adoption of existing recommendations on Vitamin D supplementation for eligible people living in adult care homes

Summary of aims and desired outcomes of Policy:

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)^[1] advice and Scottish Government vitamin D policy^[2]
• hold person-centred conversations with residents and their families about vitamin D supplementation.

National Outcome: that people are healthy and active

Directorate:

Social Care and National Care Service Development

Executive summary

The Equality Act 2010 places a duty (known as the Public Sector Equality Duty, or PSED) on public authorities to have due regard to the need to eliminate discrimination, advance equality of opportunity, and promote good relations between people who share a protected characteristic and those who do not. The Equality Act 2010 (Specific Duties) (Scotland) Regulations 2012 (Regulation 5) require public authorities to assess and review policies and practices against the three needs of the PSED.

In January 2021, the Chief Medical Officer (CMO) wrote to care homes recommending that the provision of vitamin D supplementation should be considered for all adult care home residents taking account of their needs and preferences. This was based on advice from the Scientific Advisory Committee on Nutrition (SACN) which has, since 2016, recommended an intake of 10 μg (400 IU) throughout the year for groups including adults living in care homes at risk of having vitamin D below the recommended concentration levels.

In response to feedback from the sector around the need for guidance on implementation, the CMO and the Chief Pharmaceutical Officer (CPO) asked officials to establish a short life working group (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. This led to the development of guidance which was piloted in some care homes. Using the findings of the pilot, the SLWG agreed that the guidance should be shared with care homes to support adoption of the SACN advice.

As part of this, the Scottish Government has undertaken a national equality impact assessment (EQIA) of the development and communication of guidance for care homes. This EQIA Results Report provides a summary of the key findings from the EQIA Record.

The EQIA evaluates how the policy may affect different individuals within the care home population both positively and negatively. If adverse effects are identified, efforts have been made to reduce or remove them. However, the focus is not solely on negating negative impacts, as there is also a proactive duty to promote equality. The development of the EQIA has been guided by equality legislation and addresses the protected characteristics of age, disability, gender reassignment, sex, pregnancy and maternity, race, religion or belief, and sexual orientation.

The policy to provide guidance to support adoption of the existing recommendation of people in care homes being offered vitamin D supplementation has been equality impact assessed, and it has been determined that there are no barriers to any of the protected characteristics. The policy is expected to positively impact on all eligible people living in a care home and to advance equality of opportunity for age, disability and sex. No evidence of negative impacts on people with protected characteristics has been found. The key findings section below provides a summary of the policy’s impact on individuals with protected characteristics.

Scottish Government is committed to actively consider equality impacts during the implementation the guidance to support adoption of existing recommendations on Vitamin D supplementation for eligible people living in adult care homes. This EQIA will be subject to further review and revision to ensure that any negative impacts, whether direct or indirect, on individuals with protected characteristics are addressed and mitigated.

Background

Vitamin D is important for keeping bones and muscles healthy. Current advice is that everyone should consider taking a daily 10 microgram (mcg) or 400 international unit (IU) supplement of vitamin D, particularly during the winter months. However groups at higher risk of vitamin D deficiency, including people living in care homes, are advised to take a daily supplement all year round. This advice is based on recommendations from SACN in 2016.

The SLWG set up by the CMO and Chief Pharmaceutical Officer (CPO), was chaired by a CMO Professional Adviser for Ageing and Health, and Head of Effective Prescribing and Therapeutics in Scottish Government. The SLWG comprised a range of stakeholders, including care home representatives, Care Inspectorate, pharmacists, consultant dietitian, senior nurse, clinical lecturer in geriatric medicine, NHS colleagues and Scottish Government policy officials.

The SLWG made a number of 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. The findings noted:

• 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 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 findings of the pilot, the SLWG recommended that updated guidance materials are issued to care homes to enable eligible care home residents to be 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.

The Scope of the EQIA

The Scottish Government has already issued advice that eligible care home residents should be offered vitamin D supplements as per existing SACN recommendations. The aim of the intervention is to issue guidance to support care homes to fully implement existing advice so that people can benefit from taking vitamin D.

Due to the impacts on people and to help us consider the potential inadvertent disadvantage to individuals with protected characteristics, a full EQIA was undertaken.

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 on 31 March 2022 there were 1,051 care homes for adults and 33,352 residents aged 18 years and over in care homes in Scotland^[3]. 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 e.g. pharmacists, GPs, community nurses, Care Inspectorate

Key Findings

Positive impacts of this guidance have been identified for all eligible care home residents, many of whom are older, female and disabled. Residents, who are less likely to receive vitamin D naturally through exposure to the sun, will benefit as vitamin D supports good bone and muscle health. This will be important for everyone including older people who are at risk of falls and potential fractures. There is no evidence to suggest that individuals are adversely affected by this guidance as a result of protected characteristics.

The Equality Impact analysis has allowed us to consider any differential impacts on people living in care homes with protected characteristics. The guidance will support person-centred conversations with residents many of whom are older, female and disabled to help them decide whether they wish to take vitamin D supplements. The guidance will emphasise the importance of choice. However we have considered a potential barrier to uptake for some who have dementia or cognitive impairments and who may be less able to consent. Therefore we have indicated in the guidance and assessment materials the need for families/ welfare power of attorney to be involved in the discussion and decision where appropriate.

Some residents particularly older and disabled people will be on medication given their likelihood of co-morbidities, so the guidance indicates that consideration should be taken into account of existing medicines to avoid any contraindications.

Recommendations and Conclusion

Based on the findings of the EQIA noted above and the experience of the pilot, the recommendations arising from the EQIA are as follows:

• Ensure that the guidance and assessment materials include the need for families/ welfare power of attorney to be involved in the discussion and decision as appropriate.
• Ensure that guidance includes advice on the consideration of existing medicines that people may be on to avoid any contraindications.
• Issue a specific communication to those supporting care homes e.g. GP, community nursing and pharmacy teams, to make them aware of the guidance and how they can support care homes where appropriate.
• Host workshops/webinars for care home staff and those supporting care homes to provide the opportunity to discuss the guidance and respond to any questions.
• Undertake a further review of the EQIA taking account of feedback from the sector on the implementation of the guidance to ensure that any negative impacts, whether direct or indirect, on individuals with protected characteristics are addressed and mitigated.