Naloxone kits
The data from the Naloxone Case Report Forms were complete.
Staff time to undergo training
Training data were collected from all four intervention Trusts.
Site 1 AS and Site 2 AS
Within Site 2 AS, records were available for 121 trainees with each session taking, on average, 24 minutes. Trainees were predominantly paramedics, but there were also other grades of staff including consultant paramedics and specialist practitioner paramedics. Training was undertaken by three separate people – an external contractor, a staff member of Martindale and a research paramedic. The majority of training sessions were provided one-to-one, but group training was also undertaken for groups ranging from two to six.
Within Site 1 AS, records were available for 121 trainees, averaging 22 minutes per session. Trainees were predominantly paramedics or Hazardous Area Response Team (HART) paramedics. Training was principally undertaken through a cascade approach, with early trainees going on to train other staff. A slight majority of training was group sessions with groups ranging from two to eight.
For illustrative purposes, trainee data were combined with a unit cost based on an agenda for change (AfC) Band 6 salary for a paramedic (together with associated AfC on-costs and overheads for hospital staff), which is associated with an hourly cost of £51 (2020–1 price levels). The grade of the trainer outside a research setting is uncertain, and so for the purposes of this study we considered that it would be undertaken by a paramedic (which is broadly in line with both the site 2 AS and Site 1 AS training models). This resulted in a cost per staff member trained of £40 in Site 2 AS and £40 in Site 1 AS. Due to discrepancies in the recording of groups at both sites, with group numbers not always matching the number of paramedics being registered on the same day, costs were calculated assuming all training was undertaken one-to-one.
Site 1 ED and Site 2 ED
At Site 1 ED, records were available for 109 trainees, averaging 14 minutes per session. The majority of trainees had nursing roles (55%) with the remainder being doctors of various grades. Training was principally undertaken by a research nurse, with some being provided by a consultant physician and a staff member of Martindale. The vast majority of training was undertaken in group sessions with groups comprising up to 15 staff members.
For illustrative purposes, nurses undertaking training were costed using an AfC Band 6 salary and doctors using a Registrar salary, both with on-costs and overheads, which are associated with hourly costs of £51 and £52, respectively (2020–1 price levels). For the purposes of this study, we costed trainer time at the rate of a Grade 8B Research Nurse, which is £82 per hour. Group training data included only minor inconsistencies and so these were used to in the calculation of costs. This resulted in a cost per staff member trained of £17.
At Site 2 ED, records of training were kept, but the data necessary for the calculation of costs (e.g. times, grades of staff involved and numbers present) were not collected. Consequently, costs have not been calculated.
Staff time to give training to patients
With the change in the format of qualitative data collection following the pandemic, and low recruitment, it was decided to drop the questions relating to patient training. Consequently, no data relating to this are available.
Associated health service contacts
Due to changes in the project, the request for routine data was abandoned, and so these costs could not be calculated.
Summary
The study has shown that the methods for collecting costs relating to the naloxone kits and the training of NHS staff are feasible and can take into account differences in the form of training (e.g. one-to-ones group, nominated trainers vs. cascade trainers). The unit costs used in our calculations are approximate, and further calculations are also needed to produce per-patient costs, but the feasibility of these changes is beyond doubt.
It should be noted, however, that there were some problems with the staff training data. One centre produced high-quality data, two centres generated data with some discrepancies and one centre failed to use the data collection tool at all. All of these problems are considered resolvable in any future trial.70
We have been unable to assess the feasibility of collecting patient training times via staff recall. It is unlikely that this finding represents a serious barrier to the conduct of any future evaluation of THN. However, the precise method of collection of these data is still open to question; we planned to use practitioner recall, while other methods could include prospective collection as part of the Naloxone Case Report Form. It should be noted that a UK-based evaluation of THN demonstrated that cost-effectiveness is unlikely to be sensitive to uncertainties related to training costs,71 and so this should be recognised when designing future data collection; expensive or disruptive data collection is unlikely to be worthwhile.
We were also unable to test the costing of other health service contacts. However, as stated previous, this work wasn’t strictly an issue of feasibility; the approach is feasible, although the precise way in which the data would be used needs finalising.