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

4. Options

This section contains a summary of the possible approaches and a brief look at the specific mitigation measures available.

4.1 The options

1. Do nothing

This option would mean that Scottish Government would not issue guidance for care homes on adopting existing SACN advice and Scottish Government recommendations on vitamin D supplementation for people living in adult care homes. The advice is already contained in Care Inspectorate’s eating and drinking well guidance for older people. However, awareness and adoption of this advice is low, so this option would result in many care home residents who might benefit from taking supplements, not being given the opportunity to choose to do so.

Benefits

Little/no additional work required by care home staff in offering vitamin D to care home residents

Costs

No direct financial costs. However not offering vitamin D will mean that care home residents may not benefit from the supplement which has been shown to support good bone and muscle health. A lack of vitamin D can lead to deficiency and an impact on bone and muscle health resulting in greater risk of falls/ fractures. Costs may therefore be incurred through subsequent health care/ interventions.

2. Issue a letter and point to existing advice

This option would mean that Scottish Government would simply issue a letter and recommend that care homes adopt the existing recommendations. However Scottish Government did this in 2021, and the sector called for guidance on how best to implement the existing policy in a person-centred, non-medical way. By not issuing specific advice for care homes, fewer people are likely to be given the choice of taking vitamin D supplements resulting in less people benefit from it.

Benefits

Little burden on Scottish Government as only issuing letter without guidance and promotion of existing policy.

Costs

Care homes may or may not offer vitamin D. Those that do offer it will pay around £8 per year per resident for tablets and a little bit more for liquid. The pilot showed that around 46% took up the offer, the remainder were on vitamin D for deficiency (30%), could not take it for medical reasons (17%) or chose not (6%)

3. Issue letter with guidance to support adoption and promote through workshops and other means

This option would mean that Scottish Government would issue guidance materials that have been specially developed for the sector and updated based on the pilot feedback. This was called for by the sector previously. These materials provide care home staff with the tools to hold person-centred conversations with residents and families to support decisions on whether to take vitamin D supplementation, taking account of resident circumstances and existing medicines without the need to contact GPs or pharmacists in the majority of cases. Issuing guidance with follow-up engagement and promotion with the sector would mean care homes are more likely to adopt existing recommendations around vitamin D supplementation resulting in more eligible people being given the choice around taking it.

Benefits

More care home residents likely to benefit and have greater bone and muscle health, resulting in lower risk of fractures/ falls.

Costs

As noted above there will be costs associated with the supplementation (approx. £8 per person/ year for tablets and a little bit more for liquid) and the time taken to assess offer it to residents. There are approximately 33,000 residents in adult care homes. For an average bedded home (50 beds) the time take to assess all residents and discuss further with eligible residents would equate to:

Assumptions based on experience of pilot

Time taken for 50 bedded care home to assess and discuss with resident and family / Hours

• Assessment 30mins per resident – 50 residents (both those with capacity and those without involving families and Power of Attorney PoA as appropriate). Discussion at next family/PoA visit. / 25 hours
• follow-up discussion with those taking or their PoA (50%) - 20mins x 25 residents.
  Both those with capacity and those without. / 7.5 hours
• Total per care home / 32.5 hours

As outlined below suggestions for managing this from providers include sequencing the assessments and discuss this guidance with families/PoA on their next visit to the care home.

4.2 Discussion

During the discussions with the SLWG and with others including care home providers, stakeholders supported the principle of offering vitamin D supplementation to care home residents as per existing advice and issuing appropriate guidance for the sector. It was felt that the policy will be widely accepted as being beneficial and staff would want to offer this. However some noted 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. It has been suggested by a provider that to reduce this burden, identification can be sequenced by building it in to the process of admission for new residents and care plan reviews for existing residents. In addition, staff can schedule any discussions with families at their next visit. We will reflect this in guidance.

Care home providers are likely to be impacted by the cost of supplying the supplement although costs are minimal at £8/yr for tablets and a little but more for liquid. As noted above, the pilot showed that around 46% took up the offer, the remainder were on vitamin D for deficiency (30%), could not take it for medical reasons (17%) or chose not (6%).

There is agreement from Scottish Care and Scotland Excel that the cost for the supplement is already covered by the National Care Home Contract (NCHC) food and nutrition line, however the overall costs for this line are being reviewed as providers feel it does not reflect rising food and nutrition costs generally. This may mean providers are unwilling to fund the supplement at this time, resulting in unequitable access for some.

4.3 Summary of options

Although a review of the NCHC is still ongoing, vitamin D supplementation for those living in care homes has been advised and reflected in Scottish Government policy and Care Inspectorate guidance for some time. The clear message from care homes and stakeholders when the last CMO letter was issued in January 2021 was the need for guidance for the sector to implement. Guidance materials were developed and tested through a pilot with six homes and were found to be helpful in supporting homes. The SLWG has recommended that we issue the guidance but work to promote it through engagement with the sector e.g. through workshops and through development of an app on an existing digital platform used by care homes. This approach has been approved by the CMO and CPO and therefore we recommend option 3 - Issue letter with guidance to support adoption and promote through workshops and other means. To reduce the burden on providers to identify eligible residents, it is recommended that the communications suggest that care homes consider building it in to the process of admission for new residents and care plan reviews for existing residents.