This chapter reports on a budget impact analysis to estimate the costs associated with different scenarios of paediatric powered mobility provision in the UK. As part of this analysis, a tariff of costs associated with paediatric powered mobility provision was developed.
The original objectives of the economic analysis were the development of:
cost tariffs of NHS and non-NHS costs for powered mobility interventions (i.e. equipment, training and support, and any other components) for children with mobility limitations using a multiperspective disaggregated cost–consequence framework
an economic model to facilitate a comparison of the relative cost-effectiveness of powered mobility equipment for very young children (< 5 years), compared with standard NHS practice (≥ 5 years).
After the completion of data extraction in review 1, it became apparent that there was very limited conclusive quantitative effectiveness evidence and no cost-effectiveness evidence. Hence, there were insufficient published data to allow a robust synthesis of cost-effectiveness evidence and the subsequent development of an economic model. In addition, no further relevant health economic or cost-effectiveness evidence was identified from further targeted searching.
As an alternative to the economic modelling of cost-effectiveness, we focused on costs and modelled different scenarios of providing increased access to powered mobility for children aged < 5 years with mobility limitations. We developed three hypothetical scenarios of service provision mapped on to the intervention elements outlined in the refined logic model. We aimed to illustrate the costs of early powered mobility, and the potential budget impact of increased powered mobility provision for very young children.
For the budget impact analysis, we established the costs of current provision of powered mobility to very young children (i.e. the base case), and the impact of making such provision available to all children who could potentially benefit. Provision to all by the NHS would inevitably lead to increased costs, due to a number of factors, as highlighted in the assumptions below; however, this increased cost should be considered in the light of the potential benefits to the children, as detailed in the syntheses, and additional cost implications for other services in the NHS. The conduct and reporting of the budget impact analysis follows the International Society for Pharmacoeconomics and Outcomes Research’s good-practice guidance.135
Design and methods
The collection of primary economic data was not within the scope of this evidence synthesis project. To generate cost data, we liaised with a number of different organisations and individuals both within and beyond our project advisory group, including NHS Posture and Mobility Services; the National Wheelchair Managers Forum; charitable organisations such as Whizz-Kidz, Designability and the Medical Engineering Resource Unit (MERU) of Queen Elizabeth’s Foundation for Disabled People; and various wheelchair manufacturers.
Data were also obtained from publicly available sources and publications. UK government data sets and related websites [e.g. Office for National Statistics (ONS), Department for Work and Pensions, Motability] were consulted to inform population calculations, allowances and grants available to people with disabilities and their carers.136–138 NHS data sets were used to inform numbers of users and input to costings.18,139–142 Published reference sources, published research and a freedom-of-information request were used to further inform aspects of the powered mobility costs, including staffing and equipment, and for costings of local authority spend on housing adaptations.
The studies included in the systematic review were screened for any cost or resource use information that could inform the analysis. Further targeted searching was carried out in an attempt to locate economic and cost-effectiveness data using the terms ‘children’ and ‘condition’ and an economic evaluation filter, whereby ‘condition’ referred to a list of conditions known to restrict children’s mobility, and the economic evaluation filter was the narrow filter from the Canadian Agency for Drugs and Technologies in Health.143 No further relevant economic or cost-effectiveness evidence was found from this targeted search, for either very young or older children.
In addition, detailed information on costs and resources used in the provision of powered mobility and training of children accessing assisted mobility options was obtained from personal communications with a number of NHS providers and third-sector organisations, including members of the project advisory group. [Advisory group personal communication: Amanda Allard, Council for Disabled Children; Rae Baines, Designability; Sara Crombie, Sussex Community NHS Foundation Trust; James C (Cole) Galloway, University of Delaware; Simon Halsey, TinyTrax; Susan Hillman, Newcastle upon Tyne Hospitals NHS Foundation Trust; and Krys Jarvis, Shropshire Community Health NHS Trust. Other personal communication: Ruth Everard, DragonMobility Ltd (Cambridge, UK); Roy Wild and colleagues, Go Kids Go!; Invacare Ltd (Bridgend, UK); Paula Jackson, Samantha Sterling and colleagues, Leeds Wheelchair Centre; Press and Public Relations Department, Motability UK; and Nicky Ellis, North East Essex Wheelchair Service. All personal communication took place in 2019.] Personal experiences of the pathway to obtaining their child’s assisted mobility interventions were obtained from telephone discussions with the parent members of the project advisory group. These discussions focused on what the parents had to do to get powered mobility (e.g. appointments, travel, communication, out-of-pocket expenses), so that the costs could be estimated.
Data were obtained for 2018/19 whenever possible. We originally planned to inflate any earlier cost data not covered by recent publications using the Bank of England inflation calculator;144 however, this proved unnecessary as we did not need to inflate any cost data. All of the relevant cost data were synthesised into a tariff of NHS and non-NHS costs relating to paediatric powered mobility provision, which was subsequently used to inform the budget impact analysis (see Report Supplementary Material 2 for the budget impact analysis model).
Because the literature did not provide any data on the long-term impacts of powered mobility, a long time horizon could not be used. The calculations presented therefore relate only to the cost for very young children. From communication with various wheelchair services, we assume that wheelchairs are often refurbished and used by multiple patients over the life of the device; thus, it was important to adjust costs accordingly. We therefore assumed that a powered wheelchair or starter powered mobility device for a child would be useable for 5 years, and used by two consecutive children during that time.
It is anticipated that the budget impact analysis will be most relevant to the UK NHS setting, and, owing to the availability of data sets, specifically the NHS in England. The initial approach was to take a broader societal perspective; thus, cost implications for social care providers and for the families of children requiring powered mobility are presented when available, or the expected impact of increased provision is discussed in general terms.
Patient population
For the budget impact analysis, the target population was assumed to be all children aged < 5 years with a mobility problem sufficient for referral to NHS Wheelchair or Posture and Mobility Services. In current practice, some children who could benefit from powered mobility do not receive it, as they do not meet the criteria for provision. The aim of the budget impact analysis was to examine hypothetical scenarios in which more children are referred and more children receive powered mobility.
Medical diagnoses alone cannot be used to adequately estimate a child’s capacity for movement; therefore, underlying diagnoses, conditions and diseases were not used to define the patient population. Rather, the anticipated aim was to explore paediatric powered mobility provision from a service level. Furthermore, from the systematic review, insufficient evidence was identified to support separate economic analyses for individual diagnoses. We therefore focused more generally on the provision of powered mobility to very young children. Likewise, there was very little long-term evidence to allow evaluation over time.
There is no national data set on provision of mobility equipment by age; therefore, we could not easily determine the exact number of children (across all ages) who currently receive powered mobility. Estimations of the total current population provided with powered mobility, and of the total population of very young children who could potentially benefit from powered mobility, were therefore based on available data from the NHS and ONS.
The quarterly National Wheelchair Data Collection requests top-line data from each Clinical Commissioning Group (CCG) in England, including the number of adults and children registered with and referred to wheelchair services. In the financial year 2018/19, at least 60,000 children aged up to 18 years were registered with wheelchair services.18,139–141 This is potentially an underestimate, as the data for a number of CCGs are not presented. According to ONS population data for England, approximately 24% of children aged 1–17 years were aged 1–4 years;138 applying this to the NHS data suggests that some 14,400 children aged < 5 years are currently registered with wheelchair services.
The national data collection reports 9200 new referrals of children aged 0–17 years to wheelchair services and up to 23,900 re-referrals annually. It is likely that children aged < 5 years will account for a disproportionately large number of new referrals, given that many mobility issues associated with conditions present from birth will be first noticed in this time. Anecdotal evidence from discussion with expert advisors suggests that the figure is about 80% of child referrals, suggesting that around 7300 children aged < 5 years are referred per year. Data were reported from only 182 of the 195 CCGs (93%), so it is possible that up to 7900 children are being referred nationally, which we have used as a maximum value in our calculations.
According to the NHS reference costs, of the 17,299 wheelchairs issued to children aged 0–18 years in 2017/18, 3591 were powered wheelchairs, accounting for 20.8% of wheelchairs issued.142 Applying the proportion of children aged < 5 years to those aged < 18 years from national statistics, as noted above (24%), would suggest that almost 900 powered wheelchairs were supplied to this age group; this is likely to be an overestimate given the restrictions noted. Personal communication with a small number of individual NHS services and with manufacturers suggests that, on average, annual provision of powered mobility for very young children is likely to be in single figures per service (Susan Hillman; Krys Jarvis; Paula Jackson, Samantha Sterlin and colleagues; Nicky Ellis; Simon Halsey; and Ruth Everard, personal communication). Assuming that each of the 195 CCGs supplies around two very young children with a powered mobility intervention each year, this would put the figure at somewhere closer to 400.
In addition, data from the suppliers of Wizzybug145 and Bugzi146 indicate that around 200 starter powered mobility devices were loaned to children aged ≤ 4 years in 2018. We also know that a small number of families purchase powered mobility equipment privately for their very young children. There is no way to accurately calculate how many families are doing so, but we estimate that 25 families obtain powered mobility through private purchase each year. Thus, the base-case assumption is that only 625 children aged < 5 years are receiving some form of powered mobility through the NHS or elsewhere.
The calculations here are, necessarily, based on assumptions, but they do suggest that the number of children who could potentially benefit from some form of powered mobility provision before the age of 5 years is, conservatively, at least double that of the current provision; however, realistically, this could be as high as three or four times the current provision level.
Powered mobility provision: current practice
Although powered mobility provision is not always explicitly restricted by age, very young children often fail to meet the necessary criteria and are thus ineligible by default. Individual protocols for provision of powered mobility vary from service to service, but assessment of suitability is usually influenced by considerations of ability, safety in use, supervisory elements and a child’s environment. An NHS Wheelchair Service powered mobility provision process flow chart can be seen in Appendix 11, .
There are some differences between provision for very young children and older children. Very young children who currently use powered mobility devices are likely to be from a limited or self-selecting group (i.e. their parents sought out powered mobility or they happened to live in an area where powered mobility was an option offered to them through the NHS), as there is not yet universal provision of powered mobility for children aged < 5 years. Conversely, older children are able to access powered mobility as part of routine NHS practice. Given the limitations in accessing such provision for the very young, it is possible that those very young children who are currently in receipt of a powered mobility are not representative of the wider population of very young children who could potentially benefit from such interventions.
In most cases, budgetary constraints mean that only one mobility aid is provided to each child by the NHS. As very young children are usually perceived to require a specialised buggy or manual/assistant-propelled wheelchair more urgently, services are commonly financially unable to support powered mobility for very young children. A number of third-sector organisations provide financial assistance to families seeking powered mobility, and families may be directed, or identify themselves, to such organisations, thus shifting cost and resource to the third sector. Alternatively, the NHS voucher scheme allows families to obtain a voucher to the value of the equipment prescribed by the NHS, in order to top up with other funds for another item. This is being superseded by the introduction of Personal Wheelchair Budgets, as part of the personalised health budgets, aiming to give people with long-term health conditions and disabilities more choice and control over the money spent on meeting their health and well-being needs.147 A small number of NHS services work in partnership with the third sector to offer enhanced access to powered mobility.
Intervention mix
Aside from the actual device, powered mobility interventions also include referral, assessment, fitting, training, repair and review. The following aspects were considered in the development of the tariff of costs and the budget impact analysis: the cost of the mobility equipment itself; the accessories/modifications required; resources used in repair and maintenance; the cost of any training delivered; adaptations to the home, transport and school environment; and any service staff time or other human resource required.
At present, a significant amount of provision of equipment and training is carried out by the third sector. These costs are also discussed, with a view to costing the impact on NHS or other central resources should they take on a more comprehensive approach to the provision of powered mobility for very young children.
Items for which costs were not anticipated to be affected by the type of equipment provided are also discussed.
Uncertainty analyses
The findings from the evidence review and the lack of detailed data available on the provision of wheelchairs means that there is a high level of structural uncertainty in the costing analysis presented here on current and projected provision of powered mobility to very young children. We attempted to account for this by including broad minimum/maximum cost ranges. Further investigation into the resources used in the provision of mobility equipment to this age group and the long-term implications are needed to make a more robust model. The interactive model underlying the budget impact analysis is presented in Report Supplementary Material 2.
Tariff of costs for children’s powered mobility
All relevant costs are summarised in the tariff of costs, presented in Appendix 12, Tables 48–50. The data, estimates and assumptions underpinning the cost estimates are presented in the following sections for each cost category, and the cost ranges used in the analysis are stated.
Powered mobility equipment
The systematic review and discussions with the project advisory group identified a number of ways in which powered mobility devices can be defined (see Table 5 for further information). For the purpose of this economic analysis, we focused on interventions that are currently supplied by the NHS (i.e. starter powered mobility devices and powered wheelchairs).
In addition, we included adapted ride-on toys in our analyses. Such devices are in use outside the UK, notably in the USA and Canada, and were the subject of a relatively large number of the studies identified in review 1. Although they represent a promising, low-cost approach to powered mobility provision, they are currently considered to be outside the remit of NHS practice as they do not meet the classification for medical devices. The adaptation of ride-on toys fitted with harnesses, supportive seating and/or controls through schemes such as GoBabyGo56,57 can allow very young children with mobility limitations to have relatively inexpensive experiences of independent mobility. These devices could be a future route for NHS powered mobility provision, and thus have been included in a sensitivity analysis.
Other options described in the literature have not been considered to be relevant to the NHS in the immediate future, and so are not covered in the scenario analyses presented here. This includes models and robots designed for specific research, the manufacture of which would need to be scaled up and undergo medical device assessment before use could be routinely endorsed by the NHS.
Powered wheelchairs
The price of powered wheelchairs varies widely according the features required to address individual clinical need. In addition, NHS and other providers serving the NHS will be offered discounted prices that are lower than the publicly available list price. Although, in general, powered wheelchairs are more expensive than manual wheelchairs or buggies, the actual prices paid and the relative differential between powered and manual equipment varies widely in the limited national data available; therefore, it is possible to suggest only an approximate average cost.
The NHS reference costs for children’s ‘high need’ powered wheelchairs increased over a 5-year period from £377 in 2012/14, to £1760 in 2016/17. The most recent published figures for 2017/18 state a unit cost of £656 for the basic cost of a ‘high need’ powered wheelchair for children. This is more than double the cost of ‘low need’ (£266) and > 60% higher than ‘medium need’ (£394), but only slightly higher than the cost of a ‘high need’ manual wheelchair (£646). In addition, ‘specialist modification costs without supply’ are stated to be £139.142
The Unit Costs of Health and Social Care 2018148 does not distinguish between provision for adults and children, but cites a capital cost of £1528 for a powered wheelchair, annuitised to £338 over 5 years. This is more than five times the cost for a self- or attendant-propelled manual wheelchair. Combined with maintenance revenue costs of £129, the unit cost rises to £467 per annum over 5 years. The authors of these unit costs148 cite one commercial site where costs range from £100 to £1300 for self- or attendant-propelled manual wheelchairs, and from £1000 to £5000 for powered wheelchairs.
From discussions with contacts within the NHS and the project advisory group (predominantly service providers/managers, service commissioners, commercial directors and representatives of national charitable organisations), and from reviewing the equipment cited in publications identified in the evidence review, we ascertained that the prices for powered wheelchairs for very young children are higher, ranging from £1800 to £8500. Based on the cost of chairs cited by NHS contacts and manufacturers’ list prices, our best estimate for the average cost of a powered wheelchair in this age range is £3939 (range £1800–8500). We assumed that these devices would be used by two children over the life of the chair; the cost per child is thus £1970 (range £900–4250). This is similar to the figures presented in the report Developing a Wheelchair Tariff Pilot Programme.149
Starter powered mobility devices
Starter powered mobility devices, such as the Wizzybug145 and Bugzi,146 are generally aimed at children up to the age of 5 years (or weight limit of 25 kg). Other items aimed at this younger age group offer the potential for continued use after the age of 5 years, such as the TinyTrax, with a ‘grow with me’ design, and the SnapDragon (Dragonmobility Ltd).150
These devices are not generally funded directly by the NHS, and are usually provided by loan through the third sector, either directly from the organisation or referred to by (or in collaboration) with therapists in the NHS. Families often obtain funding by application to other third-sector organisations for support, or fund the loan themselves. Manufacturers and other third-sector sites provide links to potential sources of funding. Families may privately fund the purchase entirely, although this is not thought to happen regularly.
Some professionals actively direct families to loan schemes or make them available to children through their own service. The current refundable deposit fees for Bugzi and the Wizzybug loans are between £100 and £200. The devices are loaned until the child no longer requires them, and are then returned for refurbishment for future loan. Capital costs of the items are between £3500 and £5000. Costs of provision and maintenance are often met by the supplying charity; however, in some cases, there will be extra associated costs, such as transport to the assessment/for collection and for maintenance. Based on these costs, our best estimate for the average cost of a starter powered mobility device is £4250 (range £3500–5000). Assuming that these devices would be used by two children over the life of the device, the cost per child is £2125 (range £1750–2500).
Ride-on powered toys
A number of researchers have explored building equipment to give very young children some experience of mobility through self-builds, using carts, robots and adaptations of ride-on car toys. The materials costs are relatively low in comparison with commercially available powered mobility equipment; however, the items are often bespoke for the child, so the amount of engineer resource may vary significantly according to need and the complexity of the build. The GoBabyGo scheme utilises students’ science, technology, engineering and mathematics (STEM) projects and estimates costs of the toy and adaptations as US$500.56 Our best estimate for the average cost of an adapted ride-on powered toy is, therefore, £410 (range £310–510), based on the assumption that these devices would be useable by only one child, and the similar provision of engineering resource, using STEM students or voluntary resource.
Staff time and activities
The NHS reference costs for 2017/18142 include separate unit costs for a number of activities relevant to the provision and maintenance of wheelchairs to children up to the age of 18 years, primarily associated with staff costs (i.e. physiotherapists, occupational therapists, engineers and administrative staff). Unit costs are presented for assessment (unit cost £368), modification/customisation (unit cost £139), review (unit cost £232) and repair/maintenance (unit cost £214). In the budget impact analysis, these have been combined into two costs: one for assessment, modification and provision and one for review, repair and maintenance. Costs for assessment, modification and provision are one-off costs, occurring only once for each child, whereas costs for review, repair and maintenance occur on an annual basis, assuming that reviews and subsequent maintenance are carried out annually. Therefore, our best estimate of the additional staff cost to provide a powered wheelchair is £507 per child (range £368–936). Our best estimate of the additional cost to review and maintain a powered wheelchair is £446 per year, and, assuming each child receives three reviews/maintenances during their use of the device, this equates to a best estimate of £1338 (range £1017–1365) per child.
The staff costs of assessment, provision, review and maintenance for starter powered mobility devices, such as Wizzybug and Bugzi, are typically met by the provider organisation, and are thus assumed to be included as overheads in the cost of the device. Therefore, for the purpose of this analysis, we have not included separate staff costs for third-sector staff activities.
Accessories, modification and customisation
The level of need for accessories and modifications varies widely according to a child’s needs and clinical circumstances. Some users will require additional items and adaptations such as seating and other support, seatbelts or harnesses and bags or carriers for other essential medical equipment. These may be relatively standard or require bespoke manufacture for an individual user.
In terms of modification and customisation, the national schedule of reference costs for wheelchair services includes just over 1000 units of activity for children, described as ‘Equipment, Specialist Modification Without Supply’ in 2017–18, at a unit cost of £139. Over 4500 units of activity were described as ‘Specialised Complex Wheelchair Services’, at a unit cost of £429. Neither of these was categorised further.142
The NHS reference costs assume a unit cost of £143 for a review of substantial accessories.142 Manufacturers may include the cost of harnesses, certain seating, headrests, armrests, etc., in their list price, but there may be a need for bespoke specialised supportive seating as well. It has been assumed that these would be similar for a powered and a non-powered mobility device. Other additional costs associated with powered mobility equipment include attendant or dual controls, plus additional batteries and charging equipment, both of which may run into several hundreds of pounds.
Owing to the large variance in children’s needs for accessories, modification and customisation, it is difficult to apply a single cost for these aspects of the intervention. Based on previously reported data on the proportion of paediatric wheelchair intervention costs associated with accessories, modification and customisation,151 we have used a multiplier rate of 23% to the base cost of powered mobility devices and 6% to the base cost of starter powered mobility devices to predict the cost of accessories, modification and customisation (excluding staff costs).
Training
The studies identified in the systematic review were reviewed for information on any training provided to children aged < 5 years. There was a wide variation in the duration of training interventions and settings. The number of attendances and total duration of interventions delivered in this way also varied, with some lasting several months.74,117 Several studies describe provision of an initial single session or guidance provided to the caregiver, for example Evans and Baines’s62 description of the training provided to families on receipt of the Wizzybug and training provided by Mockler et al.111 to parents of users of powered wheelchairs, in a manner presumed similar to the NHS. There was no consensus on the optimum duration/number of training sessions.
Provision of training for use of powered mobility varied widely among the NHS services contacted. Some level of training will be achieved through any trial undertaken as part of the assessment of suitability of provision of powered mobility, but this has not been costed as such for the purposes of this section of the report, to avoid double-counting. Training is also delivered by the therapists at a clinic, at home or in school, usually at the point where the equipment is provided, which may be at the provider site or at the user’s home or school. It is usually limited to showing how the controls work and observing the chair in use, lasting up to 1 hour, but could take much longer for children with cognitive impairments. Again, this has not been costed separately to avoid double-counting. Provision of training for use of the starter powered mobility devices is limited to handover, during which the charity or the partner organisation’s therapist will provide caregivers with bespoke advice on learning through play.62 Thus, training that we believe to be part of assessment/provision has not been costed separately.
More formal training sessions are provided by a number of third-sector organisations; for example, the NHS web page How to Care for a Disabled Child152 specifically refers to Whizz-Kidz153 and Go Kids Go!154 as providing free training services. Go Kids Go! provides workshops aimed at children aged > 2 years using manual and/or powered wheelchairs. Family members may also attend and some workshops are aimed at school groups, including non-users of wheelchairs. In 2017, training was delivered to almost 300 children with disabilities and > 2000 beneficiaries in total, including the children themselves, family members, school attendees and health and education professionals.155 This is one area for which the costs of powered mobility provision may be less than for a non-powered wheelchair; without balancing training (users of self-propelled manual chairs require training on balancing skills to manage uneven surfaces, kerbs etc.; powered chairs are more stable and so this element of training is not required), training sessions may be reduced from 5 to 3 hours. The overall cost of running a workshop is in the region of £2000, requiring trained professionals to run the session, and often additional support from technicians and volunteer wheelchair mentors. According to Roy Wild of Go Kids Go! (personal communication), the cost per user is around £450 (estimated range £350–550), including overheads; thus, we have used this as our unit cost for training. We have also assumed that 10% of powered mobility users access this training.
Adaptations to housing, community facilities and transport
Powered wheelchairs are generally larger and heavier than manual wheelchairs; therefore, greater and/or further adaptations to housing, community facilities and transport may be required. For example, doorway widths may need to be further adjusted. In 2003, work from Canada surveying users of powered wheelchairs found that 50% experienced barriers to use in the house, 62% found physical barriers in the workplace or at school and 56% experienced barriers in community buildings.132 Although half of those surveyed had received a wheelchair before the age of 5 years, no information is presented detailing when these issues first arose. As it is probable that, in recent years, more housing and community facilities are being designed to be accessible, information on the costs of modifications are included in the analysis.
Housing
Families with a disabled child may be able to access funding from their local authority for up to £30,000 in England to adapt the home.147 The mean grant provided is £7500 (this value includes adults, as adaptations for wheelchair use are standard and unrelated to age of user).156 The number of families accessing these grants is unknown, but is likely to be a small proportion; we have therefore assumed that 10% of children would receive funding for housing modifications before the age of 5 years, factoring in that some homes would not need to be adapted.
Costs calculated for relevant housing modifications were taken from the Personal Social Services Research Unit’s Unit Costs of Health and Social Care 2018.148 Assuming that an entrance requires a ramp (at a cost of £906 per ramp), a doorway widened (at a cost of £667 per door) and path (at a cost of £153 per path) installed, and that each child would require two entrances to be adapted, the total cost equates to £3452 (range £1726–7500) per child, which we have used for our unit cost.
Community facilities
Adaptations may be required to community buildings likely to be visited by children who might benefit from powered mobility outside the home, for example schools, recreation centres, community centres and places of worship. No specific information was found about the associated costs of community adaptation in the systematic review. Although it is assumed that the costs of providing adaptations to accommodate a powered mobility device in such spaces would be the same as for housing, as most new community buildings are already built with accessibility in mind, and many older buildings will have adaptations already in place. It is anticipated that the number of new adaptations specifically for a child using powered mobility would be small; therefore, these costs are not included in the analysis.
Transport
There are no current data on the proportion of families requiring different or adapted vehicles because of their child’s disability, nor of the relative requirement for this based on use of a powered versus a manual mobility device. However, transport is recognised as causing issues throughout the review data. In the Canadian survey,132 > 70% of respondents cited difficulty transporting their powered wheelchair. In 2003, the organisation Whizz-Kidz published findings from a postal survey106 among families of children aged < 7 years who had been provided with powered wheelchairs; 61% said that they transported the child in the car, using a four-point strap and/or ratchet clamps. The Motability Scheme in the UK allows parents or carers of children aged ≥ 3 years to use their mobility allowance to lease a car or wheelchair-accessible vehicle.137 Data obtained from personal communication with Motability UK (Press and Public Relations Department, Motability UK, 2019) indicate that, in the financial year 2018/19, 120 grants for these were made in relation to children aged < 5 years, which is < 10% of the grants awarded to all children aged < 18 years. This might be expected to increase should a greater number of this age group be given access to powered mobility options suitable for use outside the home.
Motability grant values averaged £2706 in 2018, so this has been used for our best estimate (range £2435–2977).157 We have assumed that 10% of children will receive Motability grants. Families may need to top up this funding, but the exact levels involved have not been determined for this report. Similarly, we acknowledge that there will be additional travel and associated increased costs, such as fuel and depreciation of vehicles, for travel to appointments, training, etc., but insufficient data are available to quantify this.
In terms of transport to school, local authorities are responsible for the provision of free transport in appropriate circumstances, including to children with disabilities that affect their ability to walk. Legally, transport is required to be provided for eligible children only from the age of compulsory education (5 years),158 although many authorities provide transport for eligible children from the commencement of the school year in which the child attains the age of 5 years and starts full-time education, which is more commonly at age 4 years. Provision of powered mobility suitable for indoor and outdoor use to very young children, as opposed to waiting until they reach the age of 5 years, may increase the need for provision by an extra year per child, but, because of the lack of corroborating data, we have not included this cost in the analysis.
Human resource
The human resource costs of powered mobility interventions are significant, as already highlighted by the staff costs (see Staff time and activities) and cost of home adaptations (see Housing).148,159 As noted above, for assessments, provision, review and maintenance, we have used the costs suggested in the NHS reference costs, which have incorporated relevant staff resource.
The potential impact on wider society in terms of the caregiver and the wider family, and on those involved in provision of early-years schooling, has been considered; minimal evidence of reduced need for support in school was found in the literature or in consultation with our advisors; therefore, human resource costs associated with education have not been included.
Likewise, there was no evidence on the impact of powered mobility provision on parent/family productivity; therefore, these costs have also been excluded from the analysis. Although we appreciate that, in reality, there are likely to be financial implications for families, there are insufficient data to accurately calculate this at present.
Areas of no impact
There was no evidence of impact on a child’s medical diagnosis; therefore, we have not assumed any differences in need for, or type of, medical interventions including medication or surgery, nor of any staff or other resources related to these. Although changes in children’s behaviour/independence levels may affect some other areas with cost implications, it was not possible to determine the probable impact from the literature; the evidence does not allow us to quantify by how much or in what time frame any benefits may be realised.
Defining powered mobility provision scenarios for the budget impact analysis
To estimate the change in costs associated with increased powered mobility provision, a base-case (i.e. current provision) scenario was defined and a further three hypothetical scenarios were developed (see Box 1). The costs associated with individual provision do not vary between scenarios because the budget impact analysis is based on changes to the number of referrals and powered mobility devices provided. The assumptions regarding population and resources are presented in the next section. The analysis model, based on our estimations of minimum, best-estimate and maximum levels for population, equipment and resources required, is presented in Report Supplementary Material 2. In the analyses, it has been assumed that all referred children receiving mobility equipment from NHS services will receive a buggy or assisted/manual wheelchair and that the provision of powered mobility will be an additional cost.
Assumptions used in the budget impact analysis alternative service scenarios
Base-case assumptions
Population
A total of 7300 children aged < 5 years are referred to NHS Wheelchair Services.
An additional 225 children receive a starter powered mobility device from the third sector or privately outside NHS services.
Mobility equipment
Powered mobility device costs are based on the assumption that each device will last for 5 years and be used by two children during that time, assuming that each device is refurbished and then reused once (refurbishment costs are included in repair/maintenance costs).
NHS provision is based on current NHS practice. Specific powered mobility device models are likely to vary, and may include some starter powered mobility devices: best estimate £3939 per device (range £1800–8500), equating to a cost per child of £1970 (range £900–4250).
Third-sector provision is based on reported costs from manufacturers. Specific devices include Wizzybug
145 and Bugzi:
146 best estimate £4250 per device (range £3500–5000), equating to a cost per child of £2125 (range £1750–2500).
Powered wheelchair costs and starter powered mobility device costs are multiplied by 23% and 6%, respectively, for each child, to account for customisation and modification.
Resources used in assessment, provision, handover and maintenance of powered mobility
One-off staff costs associated with the assessment, provision and customisation of powered mobility are included in the analysis: £507 (range £368–936) per child.
It is assumed that each child receives three reviews/maintenances during their use of the device: £1338 (range £1017–1365) per child, with lower maintenance frequency for less complex needs.
For third-sector provision, it is assumed that all costs associated with assessment, provision, review and maintenance are included as overheads in the cost of each device.
Training
Families of children requiring training for all wheelchair types are directed to further wheelchair training, provided by third-sector organisations such as Go Kids Go! or Whizz-Kidz, with 10% of children attending this training: £450 per child (range £350–550).
Housing and transport
It is assumed that 10% of families receive adaptations to the home associated with powered mobility provision: £3452 per child receiving adaptation (range £1726–7500).
It is assumed that 10% of families apply for a Motability grant to adapt their car for a powered mobility device: £2706 per child receiving adaptation (range £2435–2977).
Alternative service scenario assumptions
The three alternative service scenarios used to estimate the costs associated with increased powered mobility provision for very young children are defined in Box 1.
Results: budget impact analysis
The data presented in the tariff of costs in Appendix 12 and the assumptions stated in Box 1 were used to estimate the current cost of provision of powered mobility options by the NHS, additional costs due to housing and vehicle adaptation, and the cost of provision of equipment and training by the third sector. See Report Supplementary Material 2 for the budget impact analysis model. summarises the findings.
Summary of total costs associated with early powered mobility provision and results from the budget impact analysis of alternative service scenarios
Based on the results from the budget impact analysis, we predict that the NHS CCG spend on the provision of powered mobility to very young children is currently around £1.9M annually, which is < 2% of the overall reported CCG spend on wheelchair services. This is based on an assumption that 400 very young children are provided with powered mobility each year. Based on our analysis, the third sector spends > £0.5M on powered mobility provision to a further 225 children, and provision of some training in this age group. Although it appears that the costs of provision per child are lower for the third sector than for the NHS, this is largely driven by the lower costs of the equipment provided, as we have assumed that the NHS currently provides powered wheelchairs with additional servicing costs, whereas we have assumed that the third sector largely provides starter mobility devices for which these costs are included. A further £0.4M is spent on adaptations to support powered mobility through funding from public services and the third sector.
To estimate the cost of increasing supply and demand for powered mobility, we modelled hypothetical increases to powered mobility provision. In scenario A, the number of children provided with powered mobility was doubled in both NHS and third-sector provision, to illustrate the change in cost associated with a more open approach to early powered mobility provision, and based on current numbers of children referred for mobility equipment. The cost to NHS services increased to £3.8M, and the cost to the third sector increased to £1.1M.
In scenario B, we modelled a situation in which more children are also referred for powered mobility, as well as increased provision, increasing costs to £4.2M and £1.2M for NHS and third-sector providers, respectively. In the final scenario, scenario C, we developed a hypothetical situation whereby the NHS takes on all early powered mobility provision, and therefore covers all costs associated with third-sector provision. Although this is highly speculative, at present the third sector is relied on to fill the gap in early powered mobility provision, and, given the potential health and developmental benefits of early powered mobility, there is an argument that the NHS, or other centralised funding, should be responsible for supporting all provision. We therefore undertook scenario C to estimate the associated cost implications of shifting all costs for powered mobility provision to the NHS. The results indicated that NHS costs would increase to £5.6M (including an additional increase in standardised provision of powered mobility training).
Of the 195 CCGs covered by the National Wheelchair data collection, 131 reported annual spend on wheelchair services,18,139–141 indicating a total spend of > £108M. Assuming that the mean spend for each CCG providing data can be assigned to those CCGs that did not, the total figure could be in the region of £129M. The results indicate that even if the NHS were to double provision of powered mobility for very young children, and to take on responsibility for all third-sector provision, the costs would remain relatively low, in relation to the overall budget for wheelchair services, at between 4.3% and 5.2% of reported CCG costs.
Factoring in all relevant public sector and third-sector costs, the cost of an early powered mobility intervention is likely to fall below £10,000 per child. This cost could be reduced through bulk purchasing, increased repair/maintenance and subsequent reuse of individual devices. In the highest-cost scenario, the potential cost to the NHS exceeds £10M, but it is of note that this is based on the worst-case scenario for all variables, and is therefore unlikely.
Despite the speculative nature of this analysis, the results indicate that powered mobility provision for very young children could feasibly be increased without major increases to budget. Furthermore, the results could be used to inform budget allocation to support increased provision.
Outside the UK, particularly in North America, there is interest in provision of adapted ride-on toys to provide a powered mobility experience. Currently, we do not believe that access to this kind of intervention is being provided by the NHS, and have little evidence of bespoke adaptations being made outside this. However, if the NHS were to adopt a scheme like GoBabyGo in the USA, where student resource is used to adapt the vehicles, the costs are estimated to be in the region of £410 per vehicle. If every very young child with mobility needs referred to wheelchair services was offered access to such a device, the potential cost would be £3M per year (range £2.9M–3.2M). It is likely that this kind of intervention would not be suitable for all children because of their differing needs and abilities, which would reduce this cost. However, if the adaptations were to be taken on by the NHS, costs of engineer resource would need also to be taken into consideration.
In addition to the lack of conclusive data from the systematic review on the probable positive and negative influences of early powered mobility on costs, the nationally available NHS sources lack detail on the provision by age, in terms of both patient numbers and equipment costs. The scope of this project was not to undertake primary data collection for the purposes of an economic analysis. We have therefore used published NHS costs when available, supplemented by discussion with members of the project advisory group (specifically service providers/managers, service commissioners, commercial directors and representatives of national charitable organisations). Feedback suggests that the costs of equipment cited in the reference sources are likely to be underestimated, and thus the costs of service provision may also be inaccurate. However, although we have attempted to cost equipment more realistically, we have used NHS data on resource use, as we identified a wide variety of approaches used locally across CCGs and services contacted. These include the following:
differences in protocols for provision of early powered mobility that affect access, even if not categorically setting an age threshold
the number of CCGs supported by a wheelchair/posture and mobility service
use of centralisation of some aspects, for example engineering across multiple services
the level of contracting out to non-NHS providers
the level of collaboration with third-sector providers
the choice of powered mobility equipment provided and the variation in contract prices for equipment
the type and level of professional and support staff involved at different stages of provision.
There were no robust economic data on the impact on users’ families identified from the systematic review. In particular, there was no detail on the level of funding outside the NHS through top-ups to funding accessed by vouchers or personalised wheelchair budgets, or by third-sector grants. In addition, we know that individuals may fully fund the purchase of new or second-hand equipment, but the extent of this is unknown. Based on this, we acknowledge, but have not attempted to cost, this aspect.
We have not incorporated any costs associated with initial referral, which may increase from scenario B onwards. We are aware of significant staff and carer time and resource use to make a case for provision for exceptional cases, but the number is unknown; thus, we could not incorporate such cost in the analysis.
A further significant consideration is the general capacity for increasing the resource allocated to increased provision. Increased staff resource would require re-allocation and/or recruitment and training of additional staff. Our calculations have not considered any costs of new assessment equipment or new/extended buildings to accommodate increased clinics.
Scenario C makes a hypothetical transition from no collaboration with third sector to the NHS assuming all costs of provision by the third sector. However, in reality there is some collaboration now, which is likely to grow. We do not intend to imply that there is no role for the third sector in the future, only that the costs related to the provision of equipment should be covered elsewhere. For the purposes of this review, we have assumed that this is the NHS, but it could come from other central funds.
We did not attempt to make assumptions about future developments, which are likely to affect this field. It is likely that technological advances will be introduced, and therefore costs will change. In addition, the roll-out of personalised wheelchair budgets, replacing the current voucher scheme, may also affect the range of items provided and associated costs.
The awareness of and interest in the importance of early powered mobility is growing. Earlier provision of powered mobility is unlikely to change the number of children with mobility needs being referred to the NHS; however, the interaction with the service, the provision of powered mobility and associated need for adaptations, reviews and repairs will occur earlier in their lives, bringing the costs forward. The result may be that more children are referred earlier, and that more children meet the criteria for early powered mobility earlier.
We found that the most recent reference costs were far lower than the costs of powered wheelchairs reported by the CCGs we contacted, and we found a variation in the protocols and activities associated with the provision of early powered mobility. These issues were also noted in the report149 on the work carried out by Deloitte (London, UK) in the development of a wheelchair tariff generally, not just for this specific group of users. Further work is needed to determine, in more detail, the extent and cost of provision of mobility equipment and the supporting services.
