Title: Informing health services for people who use heroin and crack
Funder: Department of Health and Social Care

Abstract: Research question: The project will address three research questions to support commissioning of health services: (1) How do people who use heroin and/or crack cocaine use the NHS? (2) What are the costs of healthcare for people who use heroin and/or crack cocaine? (3) How does the health service manage long-term conditions in people who use heroin and crack?Background: People who use heroin and crack have high and increasing healthcare needs. However, there is very little evidence of how this group interacts with the healthcare system in England. This means it is difficult to make investment decisions and plan better services. The consequence of this is that health services are often not accessible, leading to high rates of A&E use and late presentation. This causes a substantial burden on the NHS, with some hospitals reporting rapidly increasing rates of presentation by people in this group.Aims and objectives: The aim is to inform commissioning of specialist and general health services for people who use heroin and crack. The objectives are to understand healthcare utilisation in two cohorts of people who use drugs, estimate national healthcare costs for people who use heroin and crack, and to develop recommendations for health service commissioning.Methods: Cohort analysis of (a) 9,577 people who use opiates or crack and have been in contact with addiction treatment services at South London and Maudsley NHS Foundation Trust (b) an estimated 59,000 people in the Clinical Practice Research Datalink who have health records that indicate opiate or crack use. The rates of healthcare utilisation in these cohorts will be applied to national population estimates of the drug-using population and health service unit costs. Patient pathways will be explored in more detail to show how management of exemplar long-term conditions (selected with input from a PPI group) differ between people who use drugs and the general population. Finally, there will be workshops with patients and professionals to identify recommendations for health service commissioning.Timelines for delivery: The project will take three years. Preparation of data and analysis of rates and causes of healthcare use will take place in year one. Estimation of costs will take place in the first half of year two. Analysis of patient pathways will be completed in the first half of year three. Dissemination will occur throughout the project and will be focused on the final six months.Anticipated impact and dissemination: The findings will be disseminated via existing academic and policy networks, including peer-review articles, conferences and Public Health England's alcohol and drugs group. There will be an event including local and national commissioners, clinicians and service users, to discuss next steps from the research. The anticipated impacts are (a) a clearer understanding of the economic and social importance of accessible primary and preventative health services, and (b) pilots of new healthcare models for the exemplar conditions.

Lay abstract: People who use heroin and crack cocaine have an increased risk of many physical and mental health problems. Some of these problems, such as hepatitis C viral infection or the risk of suicide, have been researched extensively. However, long-term conditions such as heart disease and breathing problems are poorly researched, despite becoming more common in this group. This research will examine the way the NHS manages these conditions. It will provide recommendations for services that are better at catching problems early, and therefore save money and improve health outcomes.Evidence suggests that people who use drugs can encounter difficulties in accessing and using health services, which means they often use A&E and may wait until a disease is serious before seeking help. For example, people who inject drugs can develop skin infections where they inject, but may not see a doctor before the infection spreads to other parts of the body. This can lead to poor outcomes and high costs of treatment. Some hospitals report that complex treatment for people who use drugs requires a large and increasing proportion of their resources.Recent clinical guidelines recognise that health services for people who use drugs need to be improved. However, the way this group uses the NHS has not been studied systematically. We have particularly limited understanding of how people who use drugs use GPs, which is important because GPs often provide ongoing management of long-term conditions.This research will use anonymised medical records to show how often and why people who use heroin and crack visit their GP, go to A&E and are admitted to hospital. It will also show whether these patterns are different to people who do not use drugs. This information will allow an estimation of the total costs of healthcare use for this group, which may be higher or lower than other groups.The research will also investigate journeys that patients take through the NHS. For example, some patients may visit their GP often, while other may never see their GP but occasionally go to hospital. These journeys provide insight into how well long-term conditions are managed by health services. Example long-term conditions (such as heart disease, breathing problems or epilepsy) will be chosen and typical patient journeys will be identified. This is a new approach to analysis of health services, and may identify areas where the NHS can improve the way it cares for people who use drugs.Recommendations for the design of health services will be developed through workshops with patients and professionals. Draft results of the research will be presented annually to a patient group, which will also provide advice on the design of subsequent stages. For example, the patient group will provide advice on which example conditions should be studied.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH;DISPUTED AETIOLOGY AND OTHER