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4 Health Gain and Social Inclusion

4.1 Assessing health gain

4.1.1 Clearly, many of the possible changes to the service under discussion would cost more money. Can these be justified when the NHS faces many other competing priorities? Work commissioned as part of this report suggests they can. We used economic evaluation to show what health benefits could be achieved by spending more money on the services, then applied the same rules as are used by the National Institute for Health and Clinical Excellence ( NICE). ¹

¹NICE has a remit to advise the NHS in England and Wales but its recommendations on health technologies are generally accepted by NHS Quality Improvement Scotland and issued as guidance to the NHS in Scotland as well.

4.1.2 The key concept in this approach is the quality-adjusted life-year ( QALY). This takes a period of time such as a year of life (or life-year) and weights it by a factor that reflects quality-of-life (hence quality-weighted life-years or quality-adjusted life-years). The weight is expressed as a number between 1 and 0, where 1 equals full health and 0 is a state that is as bad as being dead (negative states are also possible). So if a wheelchair improved someone's quality of life from 0.5 to 0.7 for one year, then that would be a gain of 0.2 QALYs. If the gain lasted for four years that would be 0.2 * 4 or 0.8 QALYs, and so on. If a hundred people each gained 0.2 QALYs that would be an overall gain of 100 * 0.2 or 20 QALYs.

4.1.3 A full economic evaluation of a policy or service would involve working out what the change costs (including savings) and comparing this to the additional health benefit measured in QALYs. The cost-effectiveness of the change is the additional cost per QALY gained. So if the change that produced 20 QALYs cost £300,000, the additional cost per QALY gained would be £300,000/20 = £15,000 per QALY.

4.1.4 A health economist's perspective on policy changes was included to weigh the additional costs of a change in priorities against the additional benefits, measured in terms of QALYs. The main data sources were Scottish clinical opinion and a review of published research.

4.1.5 Wheelchairs generally do not make any difference to the length of life so the main challenge is to identify the main utilities, in other words to try to value people's quality-of-life with and without a wheelchair. The values obtained from the literature were as follows:

Table 11

4.1.6 The lack of relevant, generalised economic research in this field makes estimating the QALY gains of improved access to wheelchair services very uncertain. The clinicians consulted presented a consistent and coherent picture of the types and numbers of patients who might benefit from reductions in waiting times and improved access to power chairs but the data are lacking to present a definitive QALY calculation based on these insights. Despite this it is possible to estimate the orders of magnitude involved in reducing waiting times and in improving access to powered chairs.

Reducing waiting times for a standard chair

4.1.7 The situation we have considered is reducing the wait by three months. Individuals with stable disease might be walking with a stick - in the Newcastle MS study in the table above, they might be walking with a stick, valued at 0.49. With a chair they might get to 0.64. This is a gain of 0.15 over three months. The QALY gain is 0.15 * 25% of a year, or 0.037 QALYs.

4.1.8 A more optimistic scenario would be to use the data from the IHRQoL study: in this case with a chair, their quality-of-life might rise to 0.70. This would be a gain of 0.21, and given that this lasts for three months, it is equivalent to 0.0053 QALYs.

4.1.9 NICE's guidance on an acceptable cost per QALY states that up to £20k/ QALY is usually acceptable and up to £30k/ QALY may be acceptable under certain circumstances. If NICE are willing to pay at least £20k for a QALY then they should be willing to pay £20k*
0.037 for 0.037 of a QALY. This comes to £745. If we use the £30k cut-off instead, NICE would be willing to pay £1,118. If we use the IHRQoL study then all these figures would be about 50% higher.

4.1.10 So even for the less optimistic health gain estimate, by the criteria that are used to set NHS priorities we should be willing to pay at least £745 and maybe up to £1,118 to reduce the wait by three months for one person. This is equivalent to between £248 and £373 per month of reduction per person. Under more optimistic assumptions about gain, these figures should be 50% higher.

Table 12

4.1.11 Alternative hypotheses could be constructed; for example:

• under the least favourable scenario, people are still able to walk with a stick when they are considered for a chair so the gain is much smaller, possibly in line with the final column of the table above. However, having earlier access to the chair may allow the person to stay mobile, maintaining social contacts outside the home.
• alternatively for some service users who might either suffer from pressure sores or lack of posture support, the gain might be closer to 0.25 in the first column of the table (or even higher) - the willingness to pay for a waiting time reduction in these cases is correspondingly greater.

Reducing waiting time for seating

4.1.12 This is problematic: for example, one of the benefits described by clinicians in reducing waiting times would be the (unquantified) reduction in risk of pressure sores, but further literature searches failed to locate any studies that estimated the consequences of a pressure sore in terms of QALYs.

4.1.13 However, it seems reasonable to suppose that the benefits of reducing the wait for seating will be at least as great as those estimated for 'standard wheelchairs' above. If the potential benefits are higher, as seems likely, the NHS should be willing to pay more to achieve them. The costs of reducing the wait may also be high as the services are more specialised.

Improving access to powered chairs

There are two groups of wheelchair users to consider.

4.1.14 The first group would have got a standard chair and now get a powered chair. From the IHRQoL study, the additional benefit is 0.12 per person per year (ie 0.82 rather than 0.70). To illustrate the cost-effectiveness of a powered chair, suppose the person uses a chair (whichever the type) for five years and that powered chairs cost £1,000 more than standard chairs with an additional maintenance cost of £500 per year (to really stack the calculation against the powered chair). Even if the chair is scrapped at this time, the additional cost is £3,500 and 0.6 QALYs are gained so the cost per QALY is £5,833, which is well within acceptable limits. ²

² Discounting to present values only makes a small difference to the calculation.

4.1.15 The second group might not have got a chair at all. Even making fairly modest assumptions about the benefits that a powered chair could bring to an individual, providing a chair still seems cost-effective: the costs are the same as in the example above, but now the QALY gain is 1.6 QALYs and the cost per QALY is £2,170. Again this is well within acceptable limits.

4.1.16 With this level of cost, a powered chair would be a cost-effective alternative to a standard chair so long as it yielded an additional 0.175 QALYs, equivalent to a gain of only 0.035 per year for five years. This is an extremely modest gain, and it does not include any benefits to the carer who no longer has to push the chair.

Conclusion

4.1.17 The two changes considered, reducing waiting times and greater provision of powered chairs, will both cost more money. However, the NHS frequently pays out more money for services that offer more health gain. Even the crude calculations presented here suggest that under reasonable assumptions, these interventions will be highly cost-effective.

4.2 Employability and wider economic gain

4.2.1 Some service users of working age reported that their ability to get and sustain a job is hampered by their mobility and current wheelchair equipment. While they constitute a minority within the total service user group, the impacts of facilitating their employment (by providing a chair which is more work-friendly) should not be under-estimated.

4.2.2 Recent work undertaken by Frontline for NHS Greater Glasgow and the Wise Group revealed the profound economic impact of enabling the economically inactive (as a result of ill health, including mobility difficulties) to achieve sustainable employment:

• reduction in benefits claims - the average reduction in benefits per person securing a job is £5,495 per year; this excludes reductions in housing benefit, tax credits and other benefits as a result of achieving a higher income, and
• economic output - a previously economically inactive individual securing work in Greater Glasgow generates an additional £25,700 of economic output per year.

4.2.3 Consequently, the potential value of providing a higher specification chair to an individual to enable them to work may well outstrip the additional cost of the chair.

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