Cost of aquatic therapy

The cost of AT to the NHS was estimated by taking the NHS 2013 tariff cost of AT of £110 for a first session and £74 for subsequent sessions inflated to current prices using the Hospital and Community Health Services Index.²¹⁶ We also examined some of the individual components of AT including staff time and maintenance costs. Qualitative interviews and discussions at our TMG showed that a minimum of five staff members were needed on site to run a 30-minute AT session: one physiotherapist at NHS band 5, 6 or 7; one physiotherapist assistant (NHS band 3); and three other staff (band 2 or 3). We took the midsalary point on NHS Agenda for Change¹⁶⁹ and assumed that staff needed to be available for 1 hour to deliver a half-hour session. We were unable to obtain maintenance costs directly from the centres participating in our study; however, a NHS report from trusts showed annual costs of £12,000 per year.²¹⁷

Land-based therapy was prescribed by the specialist physiotherapist during this study. Outside this study, in usual care, it would be prescribed by a community-based physiotherapist. The frequency between visits to a community physiotherapist varied between once every 6 weeks and once every 6 months. The unit cost of a physiotherapist was taken from the Personal Social Services Research Unit.²¹⁶ The exercises prescribed were then carried out by carers and teaching assistants.

Costs borne by patients

Although not a NHS cost, there is an opportunity cost to participants and their carers and family to attend an AT session; this includes time off work or usual activities for the carer, time out of school for the participant, child care costs for other children, journey time getting to the session and parking.

The intervention also included LBT two to four times a week, which may be delivered by a community-based physiotherapist, parent or teaching assistant. For NHS costs it was assumed that the community physiotherapist saw the participant once per month and that sessions were delivered by parents or teaching assistants at all other times. It was assumed that the amount of contact time the community physiotherapist had with participants was the same in both groups. However, we allowed for the fact that parents in the usual care group would have to spend more time delivering LBT, as they would have to provide, on average, three more LBT sessions than required for the AT group.

Using information from the qualitative interviews and from discussions with our PPI representatives on the TMG, we made the following assumptions about time:

• time off work or usual activities to take participant to an appointment – 3 hours
• time to look after other siblings during the session, assuming that each carer had at least one other child who would need child care arrangements – 3 hours
• time out of school for participant – 30 minutes
• travel to appointment by car – 30-mile round trip
• car parking costs.

Productivity loss was taken to assume any time taken away from usual activities by the carer regardless of whether this was time away from paid or unpaid activities. In the main analysis we excluded the time the child was taken out of school but this was then included in an alternative scenario. Costs per hour were taken from the Office for National Statistics Annual Survey for Hours and Earnings for 2015²¹⁸ and were £528 per week or £14.08 per hour. Based on the qualitative interviews it was assumed that all participants travelled to the AT sessions by car; average running costs were obtained from the Automobile Association (Basingstoke, UK) website and assumed to be, for a petrol car costing £18,000–25,000 when new and covering 20,000 miles per year (median cost and travel distance), 42.52p per mile.²¹⁹ Car parking costs were assumed to cover 1–2 hours of parking at a NHS car parking fee of £2.50.

Land-based therapy was delivered 4–6 times per week in the usual care group and 2–4 times a week in the intervention group. This tended to be shared between teachers and parents. We assumed that parents would help with LBT two or three times a week in the usual care arm and once or twice a week in the intervention arm, for approximately 30 minutes per session. Costs per hour were taken from the Annual Survey for Hours and Earnings for 2015.²¹⁸

For both NHS cost and costs borne by patients, perspectives costs are estimated per patient per session and for a 6-month block of treatment. Discounting was not applied as costs are presented over the 6-month time period of the study. All costs are presented in 2015 prices.

Attendance

Alternative costs for a course of AT were estimated after allowing for non-attendance. If the AT pool had been available for all sessions over the 6-month period, then participants would have had the opportunity to attend 52 sessions. In reality, participants were offered anywhere between 28 and 52 sessions (349 over eight participants). This resulted in an attendance rate of 58% over the 349 sessions that were offered, or 49% if all 416 sessions had been available. In 50 of the 349 sessions, participants were unable to attend and were assumed to cancel the session in advance; assuming that the pool was put to other use over this time would give attendances of 68% over 299 sessions or 55% over 366 sessions.

Results

Using NHS tariff costs, AT cost £113.88 for a first session and £76.61 for subsequent sessions. Over a 6-month course of AT this would result in a cost of £4021 over 52 sessions. Allowing for alternative attendance rates, costs of AT would range between £1970 (49% attendance rate) and £2734 (68% attendance rate) (Table 25).

TABLE 25

Summary of staff costs for AT session

Over a 6-month course of AT, staff costs would be £3504.28 and range between £1717 (49% attendance rate) and £2383 (68% attendance rate). Assuming annual maintenance costs of £12,424 for an AT pool used by a range of services and offered for 39 weeks per year during core hours would work out at £8.49 per hour.

Land-based therapy provided in its usual setting would cost the NHS between £80 and £320 over a 6-month period, assuming that physiotherapists saw boys once every 6 weeks to once every 6 months. The remainder of the costs of LBT would be borne by the carers and the education system (teaching assistants).

Costs borne by participants and their carers for aquatic therapy

Table 26 shows costs borne by participants and their carers per AT session to be £99.74 or £106.78 if including time lost by a child from being taking out of school early. These costs would rise if child care for other children was undertaken by professionals (e.g. after-school clubs or childminders rather than volunteers).

TABLE 26

Summary of activities and costs borne by participants and carers attending AT sessions

If participants attended all 52 sessions, the costs borne by them and their carers would be £5186 (£5552 if including time out of school). Costs would range between £2541 (49% attendance rate) and £3526 (68% attendance rate) if participants’ time out of school is unaccounted for or £2720 (49% attendance rate) and £3775 (68% attendance rate) if participants’ time out of school is accounted for.

Land-based therapy costs to parents in the usual care group ranged from £732.16 to £1098.24 for two or three sessions over the course of 6 months and from £366.08 to £732.16 for one or two sessions over 6 months in the intervention group; a difference in costs of £366.08. Overall, the costs borne by participants and their families for AT plus LBT could be as much as £6000 assuming attendance of all sessions, in comparison with £1098 for LBT alone.