Community First Responders' role in the current and future rural health and care workforce: a mixed-methods study

Development of Community First Responder schemes

Community First Responder schemes have supported ambulance services to provide emergency care to rural communities since the 1990s, when the UK government encouraged the use of volunteers to get help more quickly to people with emergencies in rural areas. 1,2 CFR schemes organise volunteers to support Emergency Medical Services (EMS) working with ambulance services who dispatch them to provide urgent care to patients in both rural and urban areas. 3 CFRs are members of the public or off-duty medical, nursing or allied health professionals who volunteer to reach a potential life-threatening emergency, primarily in their local community, in the first vital minutes and who provide appropriate care until more highly skilled ambulance staff arrive. 3

Volunteering has been defined as ‘any activity in which time is given freely to benefit person, group, or organization’. 4 Theories about why people volunteer have been extensively explored, and these are based on individuals’ characteristics and their relationships with others, and the community context in which they live or work. 4 From an individual motivational perspective, functionalist theory describes the importance of values (acting on values such as humanitarianism), understanding (seeking to exercise or learn skills), enhancement (the potential to grow and develop psychologically), career (access to current or future career-related experience), social (strengthening social relationships and networks) and protective functions (reducing negative feelings, e.g. guilt, or addressing personal problems) served through volunteering. 5 The first three are considered more common reasons for and more important motivators of volunteering than the last three. 5

Community First Responders need to be distinguished from First Responders, a term used widely in the USA primarily to refer to EMS staff, including paramedics and emergency medical technicians (EMTs) and also other emergency services staff such as fire service and police staff, who are trained and equipped to respond to emergencies to complement EMS in rural areas, but this term has been loosely expanded more recently to include lay people, including sports centre staff, teachers, lifeguards or workplace first aiders, who respond to an emergency. 6,7 CFRs have operated in a number of countries other than the UK, including the USA (for over four decades),8 Ireland,9 Sweden,10 Norway,11 Japan,12 Thailand,13 India,14 Uganda,15 Iraq16 and South Africa,17 but evidence for their role and activity has been obtained largely using case study, qualitative or survey methods. 3,18 Their role in different countries has varied from dealing primarily with out-of-hospital cardiac arrest (OHCA),9–13 road traffic accidents and traumatic injury14–16 to more general first aid for a wider variety of incidents. 8,17

The number of CFR schemes has grown to the current number of around 2431, using over 12,000 volunteers, in the UK. 19 A decade ago CFRs responded to around 2% of calls,1 but the literature suggests that this figure may have increased,20 particularly in the context of pressure on healthcare budgets, centralisation of health resources and workforce shortages. 21 CFRs are considered an increasingly important part of the pre-EMS care workforce both in the UK and elsewhere, especially in rural areas where it is more difficult to provide or access emergency care within a reasonable time. 1,21 Although they do not replace ambulance clinicians, CFRs are thought to add capacity and capability to an ambulance service’s response. 1

Community First Responders have been considered important particularly for providing emergency care, and particularly in rural areas,12,22 where health services are less accessible and outcomes from OHCA and trauma are worse. This is due to various factors affecting rural areas, including an older population, difficulties recruiting skilled health personnel, the centralisation of healthcare services towards larger urban communities, and longer intervention or transport times. 23,24

Another driver of CFRs in rural areas has been poorer access to EMS and the worse health outcomes that result from this. A systematic review of 31 studies from the USA, Australia, Europe and Asia found that EMS in urban areas were more likely to have shorter response, on-scene and transport times than EMS operating in rural areas and that patients in urban areas attended by EMS had greater rates of survival from OHCA or trauma. 24 In this review, rurality was defined differently in different countries because ‘the distinction between the urban and the rural population is not yet amenable to a single definition that would be applicable to all countries or, for the most part, even to the countries within a region’. 25

A number of CFR schemes in England operate as independent charities (funded by public donations) working with ambulance services or as volunteer groups overseen by ambulance services. These include specific charities such as Lincolnshire Integrated Voluntary Emergency Service (LIVES) in Lincolnshire and Hatzola (https://hatzola.org/) in London and Manchester (and metropolitan areas in other countries),26 and CFR schemes involving medical students, linked to medical schools in England. 27 CFRs are often but not always trained, equipped and managed by ambulance services, but they sometimes use marked response vehicles and may be dispatched to a variety of emergencies. 3,27,28

Community First Responders complement the work of ambulance services,22 improving a patient’s condition by arriving quickly, recording vital signs (e.g. pulse, blood pressure or temperature) and performing basic clinical techniques, such as cardiopulmonary resuscitation (CPR)9 of people whose heart has stopped (cardiac arrest), before handing care over to ambulance staff. 1,19

Organisation of Community First Responder schemes

Community First Responders are usually organised and dispatched based on their geographical location and level of training and experience, ranging, for example, from level 1 (basic) to level 4 (enhanced) depending on work experience (e.g. qualified paramedic, nurse or doctor) and training, but the number of and criteria for different levels may vary from one service to another. The training of CFRs generally consists of first-person on-scene first aid administered prior to the arrival of an ambulance,22 and covers medical topics such as emergency first aid, basic life support, airway management, CPR, oxygen therapy, defibrillator use, recognition and initial management of cardiac conditions, choking, strokes, significant bleeds and breathing difficulties. Although CFRs were developed primarily to respond quickly to life-threatening emergencies such as OHCA, their role has expanded so that they respond to different types of emergencies such as falls or patients with chronic conditions. 1,18

In participating ambulance trusts, there is a dedicated procedure whereby all incoming 999 calls are assessed for signs of critical illness or injury before the decision is made to dispatch a CFR or an ambulance clinician. The decision to dispatch a CFR is generally based on a combination of fixed dispatch criteria, clinical decision-making of the dispatcher and availability of a CFR. CFRs vary in the types of emergencies they respond to, what they are trained to do and the equipment they carry; they are classified by ambulance services according to these skills [e.g. in East Midlands Ambulance Service (EMAS) CFRs are classed from level 1 to level 6]. 1

Community First Responders can be dispatched during the day or night to a broad range of patients depending on availability and skill levels. They are not usually sent to children, pregnant women, those in labour or with acute abdominal pain or to incidents deemed unsafe because they involve violence or firearms. Ambulance clinicians are usually dispatched when a CFR is sent unless they are not available, in which case the CFR is required to seek advice from a clinician or refer the patient to other services (D Skarratts, personal communication, 22 March 2022; J Costerd, personal communication, 13 April 2022).

Effectiveness of Community First Responders

When considering the effectiveness of CFRs, attention has been focused largely on OHCA. OHCA affects around 60,000 people each year in England alone, for whom resuscitation is commenced or continued by ambulance staff. Early recognition by relatives or bystanders, accessing EMS and providing rapid CPR and defibrillation using an automated external defibrillator (AED) significantly increase the chance of resuscitation, survival and a good neurological recovery but only 55% of cases not witnessed by EMS receive CPR and only around 2% defibrillation with 25.8% being admitted to hospital alive and 7.9% surviving to hospital discharge. 29

Community-level initiatives to increase lay responders and CFRs, for example in the Heart Safe programme in Minnesota, USA, have led to greater use of CPR and AEDs by bystanders and first responders before the ambulance arrives,30 but the effect on OHCA outcomes is less clear. Another community initiative in Piacenza, Italy, ‘Progetto Vita’, has led to survival to hospital discharge of 41.4% (39 of 95) patients treated under the scheme compared with 5.9% (193 of 3271) of EMS patients.

A systematic review of observational studies of public access defibrillation (PAD) showed a high median overall survival of 40% for patients with OHCA treated with PAD, but this compared non-dispatched lay first responders with dispatched professional (fire or police officer) first responders and found higher survival to hospital discharge with the former (53.0%, range 26.0–72.0%) than with the latter (28.6%, range 9.0–76.0%). 31

In a Cochrane review of randomised controlled trials (RCTs) and quasi-randomised control studies investigating the effect of CFRs dispatched to OHCA in adults and children (older than 4 weeks of age), comparing a combination of CFRs and EMS with EMS alone for outcomes of survival and neurological function, two completed studies met the inclusion criteria, and although one noted higher rates of CPR and the other greater AED use before the ambulance arrived, neither found improvements in survival beyond admission to hospital, which was recorded in only one of the studies. 32

An evaluation of a rural CFR scheme, LIVES in England in 2003, found that around 10% of ambulance calls were attended by CFRs, and when CFRs attended they arrived first in 60% of incidents, with benefits in speed of response and high rates of patient satisfaction, but no clear advantage in return of spontaneous circulation (ROSC) from OHCA. 33

Gaps in the evidence base for Community First Responders

Evidence for CFRs’ role and activity is largely derived from qualitative or survey studies,3,18 but, despite this limitation, CFRs are broadly perceived as positive by ambulance services and communities. 1,18,22 This has led to general support for their incorporation in EMS in the UK. A Delphi study of UK ambulance service chief executives, operational leads and medical directors on future EMS design found high agreement that CFRs, including lay and health professional members of local communities, should be trained and fully integrated into the EMS. 34

A systematic review of the international literature on CFRs found that volunteers were motivated to become CFRs for altruistic reasons, wanted more feedback on their contribution to patient care and were often confused in the public mind with ambulance staff. 3 A previous interview study of CFRs’ experiences with patients and ambulance staff broadly supported these findings. 18 Whereas this latter study explored experiences and insights of CFRs themselves, the views of other key stakeholders, including service users (patients and others involved in contacting the ambulance service) and ambulance staff, were lacking from this and previous studies.

Despite considerable investment in schemes from the volunteers themselves, donations and contributions from health services, a recent scoping review identified key unanswered questions: how effective are CFR schemes, how do they achieve anticipated benefits, what do they cost, how are they perceived by service users and healthcare providers, and how might they develop and be improved in future for rural and other communities?3

The evidence for effectiveness of CFRs is unclear, even for OHCA,32 the condition for which CFRs were first introduced in rural areas. There have been few, if any, studies looking into the costs or other outcomes of care of CFR schemes. 3

Innovations and developments currently fall into two main categories: first, innovation from expanding the CFR workforce (e.g. fire and rescue services providing CFR capability), and, second, innovation in the types of emergencies CFRs attend; for example, in some regions CFRs attend older people who fall but are at low risk of injury.

As a result, further evidence is needed on how CFRs contribute to rural services in terms where they operate (i.e. rural or urban areas) and the type of calls and the demographics of the people they attend, as well as what they do, how this is perceived by various interested stakeholders, the cost of provision, what effect this has on service users and outcomes and how this could be improved or expanded. 3

This study sought to provide evidence on the contribution and costs of CFR schemes to rural health as well as how these services can be optimised or developed further to benefit rural communities.

Design

We used a retrospective observational study design. Routine data were collected for analysis from electronic clinical records accessed from 6 of 10 ambulance services in England between 1 January 2019 and 31 December 2019. 42

Data collection and processing

Routine anonymised individual patient data sets, assigned a unique (non-personally identifiable) number from the six ambulance services, were collected and analysed. These included resource type, call category, clinical condition (chief complaint and impression group), date and time, geographical location (incident postcode), demographic information (age, sex, ethnicity) and whether they were conveyed by ambulance to hospital. The data sets were standardised and cleaned to derive the same variables for all of them. Rurality was defined according to the following categories under current UK government definitions: major conurbation (A1), minor conurbation (B1), city and town (C1), city and town in sparse setting (C2), town and fringe (D1), town and fringe in sparse setting (D2), village (E1), village in sparse setting (E2), hamlets and isolated dwellings (F1), hamlets and isolated dwellings in a sparse setting (F2). 43 Rural areas were identified based on the incident postcode and a new standardised binary variable representing rurality was created with 1 assigned to rural categories (D1, D2, E1, E2, F1, F2) and 0 to the urban categories (A1, B1, C1, C2). According to the Office for National Statistics (ONS), all rural settlements have a population of under 10,000 people. Postcode records allowed linkage with Index of Multiple Deprivation (IMD) decile, ranging from 1, highest deprivation level, to 10, lowest deprivation level, which was included as another variable.

The data set obtained from the six ambulance services consisted of routinely collected clinical dispatch records from two triage systems, the Advanced Medical Priority Dispatch System (AMPDS)44 or NHS pathways. 45 The AMPDS was used by EMAS, SWASFT and YAS and the NHS pathways were used by WMAS, SECAmb and SCAS. Due to the heterogeneity and the multitude of dispatch records, the chief complaints were divided by a clinician (NS) into the following main categories: injury/trauma, cardiorespiratory, gastrointestinal/urinary, obstetric/gynaecological, neurological/endocrine, infections/allergies and psychosocial/palliative. The conditions without a specific label (e.g. other medical condition) were grouped in a category labelled as ‘other’. Examples of the most common chief complaints in each category can be seen in Appendix 1, Table 22. Thus, the dispatch data were standardised for all ambulance services. There were five call categories from category 1, the most urgent category representing an immediate response to a life-threatening condition, to category 5, a non-urgent category representing stable cases that require hospital transport. Patient age was separated into five categories: ≤ 19 years, 20–39 years, 40–59 years, 60–79 years and ≥ 80 years. Time taken to arrive, computed as the difference between arrival and dispatch time, was divided into nine categories: < 3 minutes, 3 to < 5 minutes, 5 to < 7 minutes, 7 to < 10 minutes, 10 to < 15 minutes, 15 to < 20 minutes, 20 to < 30 minutes, 30 to < 60 minutes and ≥ 60 minutes.

Statistical analysis

Descriptive statistical analyses presented numbers and percentages of call categories, condition categories, conveyance and patient demographics attended first in rural or urban areas by CFRs or other ambulance staff. Proportion tests were used to directly compare the differences between CFR and ambulance attendances in both rural and urban areas. Univariable logistic regression models were used to identify independent predictors of CFRs’ first presence on scene. To account for possible confounding effects, a multivariable logistic regression model was computed to establish which factors predicted the presence of a CFR first on scene. Due to the limited previous evidence on the role of CFRs, the multivariable logistic model used was exploratory and thus the selection of the predictor variables was not based on variables defined a priori. The only hypothesis formulated based on previous evidence was that CFRs would attend more cases in rural areas and more urgent cases given that their initial role was to attend OHCA, and this was confirmed by our descriptive analysis and multivariable logistic model.

The variables rurality, call category, condition category, age, gender, ethnicity, deprivation index, conveyance and arrival time were used as predictors and the assumptions of multicollinearity, and no outliers were checked. The assumptions of independence of observations and no multicollinearity] [Variance Inflation Factor (VIF) < 1.5] were met, and the maximum likelihood estimation method was used. The assumption of the linear relationship between continuous predictors and the logit transformation of the outcome was not checked as all predictors were binary or categorical. The predictor variables chosen were based on the descriptive statistics reported in this paper and their suitability was confirmed using DAGitty software,46 which facilitates the construction of causal diagrams and confirmed that no further adjustments were needed to estimate the effects of the predictors on the outcome.

The mathematical model representing the logistic regression given the selected predictors was:

The analysis of the multivariable logistic model was run in Stata version 16 (StataCorp LP, College Station, TX, USA) using the following line of code:

Background

There has been a lack of attention to the cost of providing CFRs. Although CFRs are volunteers, there will be inevitable costs of workforce management as well as of providing training and equipment, and possibly other expenses.

Design

We used a self-administered cross-sectional survey design to assess workforce and resources used for CFRs in the ambulance services. A bespoke questionnaire was designed for issue to ambulance trusts, asking for information on the trust workforce of volunteer CFRs, the budget allocated to CFRs and the actual expenditure incurred in managing their CFRs; data were sought for the financial years 2017–8, 2018–9 and 2019–20. The questionnaire was sent by e-mail to trust directors of research and heads of research.

The first version of the questionnaire (v1.0) was piloted with EMAS. After minor amendments arising from responses received to the pilot, a second version of the questionnaire (v2.0) was drafted and issued (see Report Supplementary Material 1) to the other ambulance trusts. The second version was not reissued to EMAS.

The questionnaire was separated into three parts: (1) human resources, (2) financial resources and (3) detailed financial breakdown. In total there were 17 questions, all but one of which asked for entry of a data value.

Background

An important aspect of the EMS response is the time taken to respond and attend, with a short wait for help contributing to patients’ experiences of care and their sense of feeling reassured that services had attended to help. 47 Response time has been used for many years to measure service quality in terms of timeliness and this is supported by extensive studies, involving a wide range of stakeholders including patients and the public as well as service providers and commissioners, into important measures of the quality and impact of ambulance service care. 48

Ambulance services are required to attend patients within a target timeframe that depends on the triaged category of the emergency. 49 The attendance targets are among the list of key performance indicators set by NHS England that ambulance services are required to meet. The attendance targets, six in total, are expressed as minimum time thresholds, applying to the following measures: the average of the time taken to attend patients by emergency severity categories 1 and 2; and the (90th) percentile in the distribution of those attendance times, again varying by emergency severity, categories 1–4. The target thresholds are listed in Table 1 (most severe = category 1 to least severe = category 4).

Design

We used a counterfactual analysis based on a geography local to the scene of the incident to estimate the timing benefit that may be attributable to CFRs’ presence compared with their absence. The counterfactual episodes are assumed to represent what the ambulance response would be without the presence of CFRs. We compared, by severity category and urban–rural classification, the travel time distributions of the CFR episodes to counterfactual episodes as well as the attendance times of both to the target thresholds.

The important reference time points for attendance targets are the time when the emergency (999) call is received by the ambulance emergency operations centre (EOC) and the time when an emergency vehicle (EV) first attends the patient. Evidence has shown that ambulance services have increasingly struggled to meet attendance targets since these were introduced in 2017. 49

Dispatching a CFR to an emergency stops the target clock if the CFR is first to arrive at the scene and attend the patient. Accordingly, first-on-scene attendance is one aspect where a workforce of volunteer CFRs may contribute value.

A second comparison focuses on travel time, from when the EV first departs to the incident until its arrival at scene. The calculation of travel time modifies the attendance time by removing from its calculation the period prior to dispatch that is due to the EOC organising the response to the emergency. The shorter the travel time, the sooner the CFR or ambulance clinician reaches the patient.

Data collection and processing

Episode data for the calendar year 2019 were supplied by EMAS in two tranches: (1) episodes of dispatch for EVs that arrived at scene, and (2) episodes involving EVs stood down pre arrival. To avoid underestimation of attendance time, it was necessary to include data from the second tranche for the circumstance in which a dispatched EV was stood down prior to arrival at scene but was later re-engaged by the EOC to the original call and did eventually attend at scene. EV attendance time calculations were constructed by including the sum of repeated durations of periods of dispatch to stood down, to which was added the time of final dispatch up to attendance at scene, which was obtained using the first tranche of data.

Key time points and data variables in the progression from the beginning of the emergency until emergency services attended at scene are displayed in Figure 2. The blue labels are variable names either taken directly from the episode data or constructed.

FIGURE 2.

Engagement of emergency services units up to attendance.

A single call number was generated for each incident and either one or many EV resources identified by call sign were allocated to each call number. Concatenating the call sign to the call number ensured that each EV involved was represented by a single unique identifier. Whether or not the assigned EV arrived was indicated using resource stood down and time resource arrived at scene. The latter was also utilised to establish order of arrival when multiple EV resources attended the same incident.

Resource type was used to designate CFR involvement, indicated in particular by ‘Community First Responder’, ‘First Responder Intermediate’, ‘Lives Responder Scheme’, ‘Medical First Responder’, ‘Mountain Rescue’, ‘RAF CAR’ and ‘Volunteer Aid Society Vehicle’. For purposes of assigning episode comparators, the following EVs were included: ‘dual-crewed ambulance’, ‘solo responder (car)’, ‘private ambulance service’ and ‘urgent vehicle’.

Urban–rural indicators were assigned to each episode according to its postcode location linked to ONS-NSPL (National Statistics Postcode Lookup) data, where the rural–urban classification is dated to the 2011 census.

Counterfactual episodes over a localised geography

The counterfactuals to CFR episodes were constructed using those episodes that did not involve CFRs occurring either at or in the neighbourhood of the same postcode as the location of the incident, ensuring a like-for-like comparison. We define this neighbourhood – the localised geography – as the next highest geography beyond postcode level in the ONS hierarchy, the ‘lower super output area’ (LSOA11). The ONS-NSPL data contain linked pairings of postcode-level and LSOA11 geographies.

Descriptive statistics were used to compare the distributions of attendance times for CFR episodes with counterfactual episodes as well as both with the target thresholds. The key assumption underlying the following comparisons was that the counterfactual episodes represented what the ambulance response would be without dispatch of CFRs.

Comparison of achievement of target thresholds

The first comparison concerned success at achieving NHS target thresholds. We computed two statistics – mean and 90th percentile – on data constructed as time resource arrived at scene less time call taken when, for CFR dispatches, the CFR was the first to attend on-scene, and for counterfactual dispatches not involving CFRs when we used the first ambulance to attend on-scene to locations within the localised geography.

Comparison of travel time to attend

The second comparison used data constructed as time resource arrived at scene less time resource mobile. This was formed across all CFR dispatches provided they attended at scene. Each CFR dispatch was matched with a counterfactual set of ambulance-only dispatches to its localised geography. From the mean of travel times of the latter, we subtracted the travel time of the CFR dispatch and term this quantity Δ where, should Δ > 0, the CFR takes less time to travel to the emergency than the ambulance. Descriptive statistics are used to describe Δ.

Design

We used a cross-sectional design linking data from EMAS and LIVES on OHCA to investigate the effect of CFRs attending on outcomes.

Data collection and processing

We were provided with routinely collected data from EMAS and LIVES for OHCA between the 999 calls to hospital transportation from electronic patient report forms (ePRFs) and data related to survival status at hospital discharge. EMAS screened their electronic clinical database of patient records for OHCA case records, dispatch codes and related clinical or treatment terms. Incidents of OHCA cases were entered into a cardiac arrest database, cleaned and verified by trained members of the EMAS clinical audit team. Outcome data on admission to hospital and survival at hospital discharge were gathered from regional hospitals for those patients conveyed to hospital under data-sharing protocols.

Data submitted included the following information:

Inputs and outcomes – whether occurrence witnessed, initial cardiac rhythm, ROSC at any time, ROSC at hospital handover, survival to hospital discharge.

Demographic information – patient age and sex, date/time of event, event location, aetiology, receiving hospital.

Interventions – bystander CPR, PAD use, other interventions, airway management.

Timing – call time, time to arrive, on-scene time, time to convey to hospital.

By examining timings provided by EMAS and LIVES, we were able to differentiate between episodes where a CFR arrived before or after EMS.

Analysis

We derived Utstein-style50 templates for OHCA incidents presenting to EMAS attended by both CFRs (LIVES) and ambulance staff. We compared outcomes for ROSC and 30-day survival using multivariable regressions models comparing CFR arrival before EMS with EMS alone for both.

Background

The falls response partnership combines the EMAS NHS Trust and LIVES Lincolnshire First Responders to form an innovative approach ensuring a safe health and social care response to people in Lincolnshire who fall. Its aims were foremost to recover the patient from their fall and then conduct a follow-up in which patient needs could be identified and appropriate service referrals made so that future falls could be prevented. In addition, the design aimed to reduce pressures on the ambulance service and emergency departments and to help retain staff at LIVES.

Lincolnshire Integrated Voluntary Emergency Service CFRs are trained and supported with two-staffed, lifting-equipped vehicles [bariatric service vehicles (BSVs)] that, when on-call, may be despatched by EMAS to attend adults who fall. Remote management of the incident from the EMAS EOC is provided by the EMAS clinical assessment team (CAT) in real time. Following treatment, the patient may either be discharged at-scene or ambulance backup may be despatched for further at-scene paramedic support and treatment with the further possibility of conveying the patient to hospital. While the service was initially designed for patients assessed by computer-aided dispatch (CAD) to have had a (least severe) category 4 fall, after approximately 2 months of operations this was upgraded to include falls assessed to be category 3 and category 2 (Box 1).

The FRP commissioned LIVES to provide an immediate patient assessment on arrival, treating the individual in their own home with basic first aid if required, assisting them back to their feet and, if the patient was then discharged, ensuring that they were in a comfortable and safe environment, with a follow-up assessment conducted within 24 hours to ensure an appropriate referral to prevent further falls. The follow-up assessment (including a standardised falls risk assessment tool) was done by LIVES and an onward referral for additional support made where appropriate. The options for further action included referral to the Lincolnshire Wellbeing Service for further assessment, support or equipment; a GP referral for assessment of frailty, dizziness, hyper-/hypotension, other medical problems or medication review; services providing strength and balance training; or to an occupational therapist working in the community falls team based at Lincolnshire Community Health Services NHS Trust for more complex needs.

The FRP was initiated in December 2018 with operating hours of 8 a.m. to 8 p.m. It began with just one EMAS-owned BSV loaned to LIVES (call sign BSV5), and a second BSV was soon added (call sign BSV4). By the end of June 2019, a total of 445 episodes of care involving FRP had been recorded. By vehicle, BSV5 responded to falls in West and South Lincolnshire and operated within the City of Lincoln, North Kesteven, West Lindsey, South Kesteven and South Holland; BSV4 responded to falls in East Lincolnshire and Boston and operated within the borough of Boston and East Lindsey.

Pilot economic evaluation

Smith et al. 35 reported on a model-based economic evaluation of the FRP during the pilot period December 2018 to June 2019 (see Report Supplementary Material 3). Their main finding was that improvement in effectiveness and cost-effectiveness of FRP compared with standard care was inversely related to ambulance backup and conveyance rates following FRP attendance, for as those rates increase so do costs and FRP patient referral rates decrease. Patient benefit, that is mitigation of the risk of recurrent falls, depended on attendance to referred clinicians, whether that be to the patient’s GP or to a community falls services or to occupational therapists at Lincolnshire Community Health Services NHS Trust. Their baseline modelling, for a hypothetical cohort of size 1000 falls patients, is given in Table 2, where the incremental cost-effectiveness ratio (ICER) by at-risk time horizon, hereafter ‘horizon-ICER’, can be selected from 1 month up to 5 months beyond the initial fall. The perspective of the analysis was the NHS, and all prices were expressed in 2019–20 values.

These results can be explained as follows. For the FRP, the model begins with 1000 falls costing the NHS in the first month £1316 per fall. Under standard care the corresponding figure is £1113; thus the incremental per-patient cost of the FRP compared with standard care is £203. During the first month, 1398 falls were predicted under the FRP, implying 398 patients with repeat falls by the end of the first month. The corresponding figures under standard care were 1448 and 448. During the first month, the baseline model predicted 50 fewer repeat falls under the FRP than with standard care for a cohort size of 1000, yielding a 1-month at-risk horizon-ICER of £4544; that is, the additional cost to the NHS of using the FRP rather than standard care to prevent one fall was £4544 for an at-risk period of 1 month beyond the initial fall. However, on extending the at-risk horizon to 5 months, the horizon-ICER reduced to £1238 per fall avoided.

A key driver of the baseline case is the differential between the rates of conveyance to hospital for falls patients; for the FRP, the observed rate over the pilot period was 68%, while for standard care the observed rate was 62.7%, a difference of 5.3% compared with the FRP. Under the FRP, a substantial cost is added when patient circumstances dictate that ambulance backup is required; in particular, estimates of the average intervention cost are £195 without backup but £440 when backup is required. 35

A scenario analysis that examined variation in FRP backup rates (set between 62% and 68%) resulted in Figure 3, which displays the horizon-ICERs against a continuum of conveyance rates. Improvement occurs as conveyance rates fall (i.e. moving from right to left on the graph) and is uniform at any selected at-risk time horizon.

FIGURE 3.

Horizon-ICER by FRP conveyance rate.

For example, matching the FRP backup rate to that observed in standard care (62.7%), with all other factors held constant, the value of the 5-month horizon-ICER dropped to £192 per fall avoided. Indeed, further extrapolation beyond that depicted in the graph to the FRP backup rate of 56.3% finds FRP dominating standard care at every time at-risk horizon, and FRP becomes cost saving at this point.

The LIVES-EMAS FRP was recommissioned by Lincolnshire County Council in February 2020. In this study we revisit the FRP and examine its operation using descriptive statistics over the period April 2020 to December 2021 using a cross-sectional design that linked FRP episode data from EMAS and LIVES.

Background

The documentary analysis addressed the research objective of understanding CFR structures (e.g. guidelines, protocols, personnel, equipment, training) in participating ambulance services.

NHS England’s Five Year Forward View51 emphasises community engagement in decision-making as a means of strengthening future health and care services. The CFR schemes have been in line with the community engagement initiative, and over 2500 CFR schemes have been operationalised in the UK. Keeping the diverse range of CFR schemes in mind, we aimed to conduct an inquiry into policies, protocols and guidelines developed for the regulation of CFRs.

Design

We conducted an analysis of ambulance/CFR policy, guideline and protocol documents in participating ambulance services using content and discourse analysis to understand current structures for CFR involvement. 52

Collection of documents

We requested CFR leads and managers in the ambulance trusts to provide documents developed as policies, guidelines and protocols for CFR roles. We analysed the documents using a comparative method by employing an institutionalist approach to policy analysis. 53 In establishing and developing public policy, the institutionalist perspective outlines the roles of the state or a government body in developing procedures and relationships between policy-makers and those that are subject to policy and how the latter are affected. Our analysis used two prominent document-analysis methods, namely content analysis and discourse analysis. 53,54

Content and discourse analysis

Content analysis was used to quantify the occurrence of certain key words, phrases, topics and concepts in the policies, guidelines and protocols retrieved. The discourse analysis developed themes that were identified from the content analysis and focused on how the CFRs were discussed in the policy documents, including how CFR roles were structured, the governance mechanism, support services, training and equipment.

Background

The aim of the qualitative study was to explore the experiences and perceptions of CFR stakeholders on the current roles of CFRs, governance of CFR schemes, challenges, solutions and future opportunities. The objectives of this aspect were:

1. to explore patients’ and relatives’ experiences and perceptions of care provided by CFRs

2. to explore the experiences and/or perceptions of ambulance staff, CFRs, CFR scheme organisers, primary care staff and commissioners on the CFR role, the governance of CFR schemes, and the potential for further development of and innovation in the CFR role

3. to explore the views of CFRs and CFR scheme organisers about challenges and solutions to recruiting, training and retaining CFRs in rural areas.

This section addresses the study objectives by analysing primary qualitative data from a range of stakeholders involved in the operation of CFR schemes, that is CFRs, CFR leads and managers, ambulance staff, commissioners, and patients and relatives of the patients.

Design

Qualitative methods seek to elaborate the views and beliefs of participants to understand complex social phenomena,55 and it was appropriate to address the research questions, which required an exploration of the operation of CFR schemes, particularly the experiences, perceptions and actions of stakeholders involved in the CFR processes. Therefore, we adopted an interpretivist paradigm of research and conducted this qualitative study in six rural ambulance services and regions in England, UK. The six research sites were rural ambulance services, which enabled us to explore and understand the functions of CFR schemes in rural health care, where CFR services are crucial.

Recruitment

The selection of participants was informed by the concept of purposive sampling56 to include a diverse range of stakeholders and their perceptions, experiences, practices and innovations until data saturation was achieved. 57,58

We purposively sampled patients, relatives and ambulance staff identified from records of patients who had been attended by a CFR in a rural location in the previous 6 months using the quantitative data from ambulance services in the cross-sectional study above. For each ambulance service, from the data set provided, a random sample was generated of 100 incidents where a CFR had attended a rural emergency in the latter half of 2019. The data set included details of patient age group, sex and ethnicity, together with chief complaint, clinical impression, incident rurality, IMD, call category, AMPDS code and outcome (see and treat at scene or see and convey to hospital). To recruit participants, the ambulance services were asked to contact the patient, CFR and ambulance staff members for tranches of 10–20 incidents, ideally with all three involved in the same incident.

Although we sought to interview patients, relatives, CFRs and ambulance staff attending the same event, this was only achieved for one set of interviews. Ambulance staff were also recruited through ambulance service research leads. CFRs were also recruited through ambulance CFR leads and we sought to recruit CFRs, patients and relatives through social media (X, San Francisco, CA, USA). Primary care commissioners were recruited through the National Ambulance Commissioner’s Forum.

We sought to recruit a maximum variation sample of patients (according to age, sex, condition and ethnicity), ambulance staff (sex, experience, ethnicity and role), CFR (sex, ethnicity, length of experience, skill level) and CFR scheme leads (independent charity and ambulance trust oversight schemes). We also advertised the study and recruited via internal advertisements, e-mails and social media at the ambulance services involved in the study and their associated CFR schemes.

Data collection

Three researchers (VHP, JP and IT) conducted the interviews using separate interview schedules for each participant category (see Report Supplementary Material 2). These were developed based on the participants’ roles and responsibilities to discuss and explore a wide range of experiences and practices in the CFR functions. The interviews took place between April 2020 and December 2021, which was in the midst of the COVID-19 pandemic and frequent nationwide lockdowns and led us to conduct the in-depth interviews online. 59 The interviews were audio-recorded with the participants’ written consent and subsequently transcribed. The length of the interviews ranged from 30 to 60 minutes.

Data analysis

We familiarised ourselves with the interviews and the emergent data through reading the transcripts. A thematic analysis approach guided the data analysis. 60 The thematic analysis consisted of several steps in which we (GP, VHP, JP and NS) organised and synthesised data by constructing short-codes, grouping the short-codes and synthesising meaning based on more broadly identified themes. Three researchers (GP, VHP and JP) used NVivo12 (QSR International, Warrington, UK) to inductively code the transcripts, periodically compiled to produce a comprehensive list of codes as they were identified from the data. The codebooks were combined to create a coding framework, and the framework was then amended following a series of discussions within the research team (GP, VHP, JP, IT and NS). NVivo12 supported the production of data outputs for each code. GP and VHP extracted the data outputs and documented the variations in practices, governance and experiences of CFR operations within each ambulance service. They further collapsed the similar themes and organised them under higher-level themes. The data outputs were read, reviewed and re-read to identify overarching themes.

Data debriefing with PPI and information validation for improved methodological rigour are discussed later in this chapter.

Background

A consensus workshop of stakeholders was convened to present and discuss recommendations developed from the earlier studies and to prioritise recommendations for development and innovation in CFR schemes. We applied nominal group technique (NGT) methods to innovations relevant to the current and future roles of CFRs.

Design

We used a mNGT as a consensus method to introduce, generate, discuss and prioritise actual and potential innovations for CFRs and CFR schemes, particularly focusing on those in rural areas. The mNGT, also termed expert panel method, is a structured, facilitated, face-to-face meeting of key informants designed to generate ideas, agree a list of those most relevant through discussion and rank them through two or more rounds of voting to reach a consensus, if possible, on the priorities for innovation. 61,62 The modifications of the original NGT introduced in this study included use of a hybrid meeting format, allowing in-person and online participation, together with introduction of learning from previous quantitative and qualitative components of the wider study. Important to NGT is a combination of qualitative (discussion) and quantitative (voting or ranking) methods to understand why certain innovations are prioritised more than others.

Recruitment

We invited stakeholders and representatives from seven rural regional ambulance services in England to the consensus meeting. We ensured that experts from different disciplines were invited, including patient representatives, CFRs, ambulance clinicians and leads. Although the consensus meeting took place in 2022 after the majority of the adult population had been vaccinated against the SARS-Cov-2 virus, cases of COVID-19 were still high in England, travel was affected and some individuals were still at risk and therefore avoiding meetings, so we organised this as a hybrid face-to-face and online meeting. We checked participants’ availability and preference for mode of participation, either face to face at the University of Lincoln campus or online via Microsoft Teams (Microsoft Corporation, Redmond, WA, USA). A list of participants was finalised based on their consent to participate.

Structure

The consensus meeting was structured in four stages or sessions: (1) presentation of information to all participants; (2) silent generation of ideas, and discussion in small groups; followed by (3) voting on ideas, feedback and discussion by all; and (4) a final vote, discussion and summary by all participants. Each session was facilitated by the chief investigator, with members of the research team facilitating small-group discussions to ensure that all participants’ opinions and ideas were included and discussed throughout the consensus process. Participants were allocated in advance to small groups to ensure that each group represented a diverse range of stakeholders, ambulance services and regions.

Data analysis

The ranking or prioritisation of innovations was achieved using a joint information systems committee (JISC) online survey (www.jisc.ac.uk/online-surveys) circulated to participants so that they could vote anonymously during the consensus meeting. All the innovations presented, suggested through the generation of ideas, and discussed were collated and entered into the JISC survey. These were rated individually by participants (excluding research team members) using a Likert scale of 1 to 5, with 1 representing ‘not a priority’ and 5 representing an ‘essential priority’. The first survey was administered during session 3, followed by a discussion and a further survey during session 4. The results at the end of each round were exported to Microsoft Excel^® (Microsoft Corporation, Redmond, WA, USA) and these were ranked using median scores and interquartile ranges.

The discussion (qualitative component) during the consensus meeting was important for understanding why certain innovations were ranked (quantitative component) above or below others. The consensus meeting was audio-recorded and transcribed verbatim for later analysis. We used inductive and deductive thematic analysis60 to explore the varying viewpoints on the innovations presented and discussed. This involved reading and re-reading transcripts and inductive coding using NVivo 12. Later, a deductive analysis was performed, based on the attributes of innovations framework. 63

Background

The importance of PPI in health and social care research has been widely accepted in the UK and supported by funding bodies such as the National Institute for Health and Care Research (NIHR) and patient organisations such as Involve (https://involve.org.uk/). In the last decade, public engagement in research has shifted from the passive provision of data as research participants to a much more active role working alongside researchers to design, develop, conduct and disseminate research. 64 In this study, we included two public contributors as co-applicants and research team members, both members of the HAPPI group, a wider PPI panel recruited for this study and a public member of the oversight committee. In the following section we describe how the partnership between researchers and PPI members informed and facilitated the research activities.

The patient and public involvement panel

On the advice of the oversight group, we expanded our public contributors on the study. A group of seven patient and public representatives were selected from a pool of expressions of interest received from open recruitment through the NIHR Applied Research Collaboration East Midlands to other Applied Research Collaborations and related organisations. We selected members to ensure a wide geographical representation to include the regions of participating ambulance services and to ensure wider representation of people of different sex, ethnic minority status and disabilities. 65

Professional advisory groups as stakeholders

We engaged with a number of key professional stakeholder groups during the study. The National Ambulance Research Steering Group (NARSG), which was composed of research leads from ambulance services in the UK, was involved in the initial design of the study and recruitment of participating sites. This group reports to the National Ambulance Services Medical Directors’ group, which itself reports to the Association of Ambulance Chief Executives. We also engaged with the College of Paramedics Research and Audit Committee through its chairperson, also a member of NARSG, and with the National Ambulance Service First Responder Managers’ Forum. We invited members of these groups, and they attended the consensus workshop.

Summary

The PPI panel members in this study were recruited to increase geographical and demographic representation. The public contributors and professional advisory groups contributed throughout the various aspects of the study, providing input on study design, advising on recruitment, reviewing findings, and contributing to the study steering and oversight groups and the consensus workshop.

Rural versus urban

We found 4,501,274 separate ambulance attendances to individual patients in the sample from the six participating ambulance services (see Appendix 1, Figure 16). Missing data varied for the variables used, from no missing data for deprivation or rurality to high rates for ethnicity (see Appendix 1, Table 20).

Of these ambulance attendances, 3,671,512 (82.8%) were in urban areas and 763,553 (17.2%) were in rural areas. CFRs were present overall in 136,438 (3.0%) and arrived first in 86,880 (1.9%) of these calls.

Community First Responders were present on scene first for 3.9% of all rural attendances and for 1.5% of urban attendances (Table 3). Proportion tests indicated that CFRs attended first on scene for a statistically significant higher proportion of the calls in rural than in urban areas.

Call urgency

Community First Responders attended more than 9% of the total number of category 1 calls and almost 5% of category 2 calls, with a statistically significant higher proportion of more urgent call categories 1 and 2 in both rural and urban settings. While 14.4% of CFR first attendances in rural areas were for category 1 calls, only 5.8% of ambulance staff attendances in rural areas were for category 1 calls. Similarly, 14.2% of CFR first attendances and only 7.4% of ambulance staff attendances in urban areas were for category 1 calls. When looking at category 2 calls, these represented 67.3% of CFR first attendances in rural areas and only 56.4% of ambulance staff first attendances. The results were similar for urban areas, with 70.8% of CFR first attendances for category 2 calls and only 55.8% of ambulance attendances for category 2 calls. Compared with ambulance staff, CFRs also attended a statistically significantly lower proportion of category 3 calls in both rural and urban settings and of category 4 calls only in rural settings. Detailed results can be seen in Table 4.

Clinical conditions

Community First Responders attended a statistically significant higher proportion of people with cardiorespiratory and neurological/endocrine conditions. The most common cardiorespiratory conditions were breathing difficulties, chest pain and stroke, whereas the commonest neuroendocrine conditions were loss of consciousness or fainting, convulsions and hypo- or hyperglycaemia (see Appendix 1, Table 22).

In the overall sample, 30.2% of CFR attendances were for cardiorespiratory conditions while only 19.2% of ambulance staff attendances were for this condition category, and 13.4% of CFR attendances were for neurological/endocrine conditions compared with 8.8% of ambulance staff attendances. Detailed results with differences between rural and urban areas can be seen in Table 3 (and differences by ambulance service are shown in Appendix 1, Table 21). An important proportion of CFR attendances was for injury/trauma conditions (20.1%), but this was lower than for ambulance staff attendances (23.2%). CFRs also attended a lower proportion of gastrointestinal/urinary and psychosocial/palliative conditions than ambulance staff, as seen in Table 5.

Comparison across ambulance services

Community First Responders first attendances compared with ambulance staff first attendances across all ambulance services presented a series of common characteristics, including the higher percentage of attendances in rural areas (see Appendix 1, Table 21), a higher percentage of attendances for the most urgent call categories 1 and 2 (see Appendix 1, Table 23) and for cardiorespiratory and neurological/endocrine conditions (see Appendix 1, Table 24).

Conveyance to hospital

On average, the percentage of patients conveyed to hospital by ambulance services when CFRs were on scene was slightly lower in both rural and urban settings. The difference was small (about 2%) but statistically significant (Table 6). The demographic characteristics of patients are represented in Table 7.

Predictors of Community First Responder attendance

Univariable and multivariable logistic regression models determined the factors predicting CFRs presence on scene (Table 8). For the multivariable model, the assumption of no multicollinearity (Spearman’s rho < 0.7, the highest value being 0.28) was met, and the model showed a good fit to the data [χ²(25) = 12,887.51, p < 0.001]. The main predictors of CFR presence were rurality [odds ratio (OR) 2.05, 95% confidence interval (CI) 1.99 to 2.11; p < 0.001], conditions including cardiorespiratory (OR 9.20, 95% CI 5.08 to 16.64; p < 0.001) and neurological/endocrine (OR 9.26, 95% CI 5.12 to 16.77; p < 0.001) and call categories 1 (OR 5.19, 95% CI 3.86 to 6.99; p < 0.001) and 2 (OR 4.44, 95% CI 3.31 to 5.96; p < 0.001), with the narrow CIs indicating that their estimates were extremely precise. CFRs were also less likely to attend patients from minority ethnic backgrounds, those from more deprived areas and those aged < 39 years.

Summary

We analysed 4.5 million incidents from six English regional ambulance services during 2019, before the COVID-19 pandemic. CFRs attended first a higher proportion of calls in rural areas (almost 4% of calls) than in urban areas (around 1.5% of calls). They were significantly more likely to attend rural (vs. urban) areas and higher-priority emergency or urgent (category 1 and 2 compared with category 3, 4 or 5) calls for cardiorespiratory and neurological and endocrine (vs. other emergency) conditions but also attended lower-category calls for conditions such as falls. They were also significantly more likely to attend older (vs. younger), white (vs. minority ethnic) people in more affluent (vs. deprived) areas, even after taking rurality into consideration.

Survey responses

Of the six trusts sent the questionnaire, responses were obtained from the following: EMAS NHS Trust, SCAS NHS Foundation Trust, SECAmb Service NHS Foundation Trust, WMAS University NHS Foundation Trust and YAS NHS Trust.

Some trusts provided incomplete data because resource data were either not collected or not available, and where costs data were incomplete, this was because CFR operations were not separately disaggregated from the wider operations of the trust.

Community First Responder workforce

Yorkshire Ambulance Service supported the largest number of CFRs in each financial year and SECAmb the smallest (Table 9). Among the four trusts supplying counts across each financial year, CFR numbers increased over time at just one, SCAS, averaging approximately + 30% year-on-year, while at the other trusts numbers declined, averaging approximately −10% year-on-year.

South East Coast Ambulance was the only trust to record that its complement of CFRs was less than fully active (‘active’ defined here as CFRs being available on-call at least once during the financial year, which is less stringent than the minimum 20 hours per month of volunteering sought by trusts); in particular, 63% was the least proportion active, occurring in 2017–8.

In 2019–20, a total of 570 new volunteers were recruited across the four trusts reporting counts, while 501 volunteers left their role as CFRs.

South Central Ambulance Service was the only trust to record the age-sex distribution of CFRs, with between just under two and up to three times more male CFRs than female CFRs, and an age distribution that saw on average 17% of CFRs aged > 65 years while 22% on average were aged 18–35 years; in the other two age ranges, 36–50 years and 51–65 years, both averages being just over 30%. Across all three financial years, WMAS reported a male-to-female ratio of 60 : 40.

Community First Responder work patterns

South Central Ambulance Service and YAS recorded the on-call working pattern in 2019–20 of their typical CFR as follows:

• average duration on-call: 7 hours

• average number of on-calls per week: 0.94

• percentage solo operating: SCAS – 100%, YAS – 95%, SECAmb – 96%, WMAS – 60%.

Community First Responder work location

Table 10 records the geographical distribution (rural, urban or both) of CFRs’ area of operation. Only SECAmb had a roughly equal urban–rural split between location of operations of their CFRs workforce. EMAS and YAS showed CFRs operating more often in urban locations, whereas for SCAS and WMAS operations conducted in rural areas were more frequent.

Community First Responder training

Community First Responders across all trusts were reported to have undertaken at least one training course per year. A variety of courses were undertaken ranging from those provided internally by trusts through to external certificate courses. SCAS, SECAmb and YAS all ran internal courses, the last exclusively so for its 900 CFRs in 2019–20. The in-house training taken in 2019–20 by 719 SCAS CFRs was supplemented by a higher-ranked level 3 CFR course taken by 114 CFRs. SECAmb’s internally governed CFR course was taken by 86 CFRs in 2018–9 and then replaced in 2019–20 by courses from FutureQuals^® [Future (Awards and Qualifications Ltd), Coalville, UK] suite of level 3 First Responder on Scene, taken by 131 CFRs. CFRs at EMAS received training courses from the BTEC (Business and Technology Education Council) ‘first person on scene’ suite; in 2019–20 numbers were level 4 Enhanced 15, level 3 Intermediate 357 and level 2 Basic 264. However, in 2022–3, these BTEC courses were no longer offered, having been replaced with new regulated versions. WMAS also used courses from FutureQuals^® Level 3 for its lower-level training and for higher levels of training courses from the Institute of Health Care Development^® (Edexcel, London, UK) ‘first person on scene’ suite.

Financial resources

Aggregate costs for CFR budget and expenditure are summarised in Table 11.

The South Central Ambulance Charity (SCAC) supplemented financing provided by the SCAS trust and fully supported CFR operations. Combining SCAS and SCAC, net of estimated provisions due to co-responders, the 3-year grand averages were just over £725,000 for both budget and expenditure. When expressed per CFR, budget and expenditure average £1142 per year and £1163 per year, respectively. This average does, however, mask the large, per-CFR, drop in budget and expenditure resulting from the upswing in CFR numbers, from, respectively, £1456 and £1531 in 2017–8 to £890 and £816 in 2019–20.

The large disparity between the SECAmb CFR budget for 2017–8 and SECAmb CFR expenditure in that year, over £284,000, was largely due to an underspend in equipment and maintenance amounting to £187,000. This is consistent with a possibly lower than expected active CFR rate, 63%, experienced in that year. In the next two financial years that gap had largely disappeared, with a slight overspend in 2018–9 followed by an underspend in 2019–20, and activity rates had started to climb back towards 100%. The budget provision per CFR averages £1252 per year, while incurred expenditure per active CFR averages £1378 per year.

West Midlands Ambulance Service does not determine an annual budget provision for CFR operations. Unlike the other trusts, large cost items such as CFR support staff are not attributed to CFR operations at WMAS. The magnitude of expenditure on CFR operations reported by WMAS if compared with, for example, SECAmb, which has had similar numbers of CFRs to WMAS, totals approximately 10% of that spent at SECAmb. Mileage reimbursement for the use of personal cars accounts for over 60% of expenditure at WMAS. This was followed by equipment, at least in 2017–8, when AED batteries and pads were replaced in large numbers (since then these items have been provided through local community efforts until 2022–3, when funding by NHS Charities Together commenced), added to which consumable equipment was provided to CFRs at local hubs. From 2018to 2019 replenishment practice for CFRs changed to replacements taken from stocks held by ambulances on scene, the cost of which is attributed elsewhere by the trust.

Yorkshire Ambulance Service provided financial figures for two of the three financial years sampled, 2018–9 and 2019–20. There was underspend of budget in both years, substantially so in 2019–20 by over £100,000. The wages of CFR trainers were by many times over the largest item at YAS, amounting to almost 70% of the total expenditure in 2018–19 and increasing to almost 80% in 2019–20. The CFR budget averages £913 per CFR per year, while expenditure in 2018–9 was £906 per CFR, dropping to £782 per CFR in 2019–20.

Community First Responder support staff

Staff numbers were reported by SECAmb and YAS, totalling under 10 full-time each year at SECAmb and under 20 full-time each year at YAS. Most CFR support staff at YAS were trainers, who were required in large numbers as, unlike at the other trusts, all CFR training at YAS was internal, numbering 16 trainers in 2018–9 and 15 trainers in 2019–20. At SECAmb there were two CFR trainers in each year. Including other staff (CFR team managers, co-ordinators and administrators), the total cost of CFR support staff at YAS averaged £690,000 per year had and £338,000 per year at SECAmb. The wage bill per support staff member at YAS averaged £36,000 and at SECAmb averaged £44,000.

Equipment

A detailed breakdown of equipment was given by SCAS, when purchases were funded by SCAC. The item of largest expenditure reported was Mangar Lifting Cushions: £50,000 in 2018–9 and £21,000 in 2019–20. This was followed by CFR Observation Kit and Bag, £9000 in 2018–9 and £2000 in 2019–20. Other equipment provided by SCAC for CFRs included pulse oximeters, defibrillator batteries, Terrafix (Stoke-on-Trent, UK) devices and tympanic thermometers.

Mileage

Mileage reimbursements were recorded by two trusts, SECAmb and WMAS, at per-mile rates of £0.45 and £0.56, respectively. CFRs at these trusts were reimbursed for travel totalling 294,838 miles across the three financial years, yielding an average (the SECAmb calculation uses counts of active CFRs) of claimed travel per CFR of 111 miles per year. A third trust, SCAS, recorded claims for mileage for January–March 2020 totalling £890.78 for 1978 miles travelled. The claims, attributable to personal vehicle use by CFRs, were reimbursed through SCAC.

In contrast to WMAS, where CFRs use personal cars when on despatch, SCAC provided CFRs with a fleet of cars, 35 in 2018–9 and 38 in 2019–20 (see fleet pictured at www.scas.nhs.uk/what-we-do/community-first-responders/). Each car was restricted by corporate agreement to not exceed 5000 miles per year, which resulted in rotations in the allocation of vehicles to keep under that limit. The combined costs of purchase and maintenance of the fleet averaged £307,000 per year.

Summary

Community First Responders varied in number between 400 and 900 across ambulance services, but substantial numbers were active and available for duty. They were distributed in both rural and urban areas to different extents across different service regions. In the two trusts providing this information, the average duration on-call was 7 hours, with on average one shift per week provided and CFRs mostly operating alone, although one trust had two-fifths of CFRs operating in pairs. The costs of providing CFR schemes varied approximately 20-fold between ambulance services from £40,000 to over £800,000 per year. Costs were incompletely recorded and reported, which may have partly accounted for this. True costs, because of under-reporting, may have been at the upper end of or even higher than these figures. Costs were attributed to staff providing management and training, together with reimbursement of out-of-pocket costs of volunteering including fuel and vehicle use.

Comparison of achievement of target thresholds

When CFRs were dispatched, all but one of the eight 90th percentile thresholds were attained, whereas the ambulance response alone failed to meet the target in every instance but one. For mean attendance time, the targets were universally missed whether or not CFRs were dispatched (Table 12).

Comparison of travel time to attend

The results comparing estimated travel times for CFRs with ambulance vehicles are shown in Table 13. Apart from life-threatening category 1 emergencies occurring in urban areas when an ambulance EV took less time on average to travel to the scene than a CFR (8.04 vs. 9.17 minutes), the results for all other combinations of severity and urban–rural location show a time advantage in favour of CFRs. This was further accentuated in rural emergencies, when the gap in travel times becomes uniformly larger relative to urban emergencies. This is further evidenced by the smoothed estimate of the distribution of differences given in Figure 4, where the bulk of the area underneath the smoothed distributions lies to the right of zero in all but one case.

FIGURE 4.

Smoothed distributions of differences (ambulance-CFR) in travel times Δ by emergency severity and urban–rural classification. (a) Category 1, urban (kernel = epanechnikov, bandwidth = 1.0071); (b) category 1, rural (kernel = epanechnikov, bandwidth = 1.3756); (c) category 2, urban (kernel = epanechnikov, bandwidth = 0.8443); (d) category 2, rural (kernel = epanechnikov, bandwidth = 0.9802); (e) category 3, urban (kernel = epanechnikov, bandwidth = 1.4396); (f) category 3, rural (kernel = epanechnikov, bandwidth = 1.9948); (g) category 4, urban (kernel = epanechnikov, bandwidth = 4.5208); and (h) category 4, rural (kernel = epanechnikov, bandwidth = 3.4505).

Summary

There was a clear advantage in terms of shorter response time when CFRs attended than for an ambulance response alone, and this was amplified when the incident occurred in a rural area.

Utstein templates

We present data in the internationally recommended Utstein style50 for OHCA incidents presenting to EMAS attended by both CFRs (LIVES) and ambulance staff (Figure 5), by ambulance staff only (Figure 6) and when a CFR attended before ambulance arrival (Figure 7).

FIGURE 5.

Cardiac arrest incidents linking LIVES and EMAS data. VF, ventricular fibrillation; VT, ventricular tachycardia.

FIGURE 6.

Cardiac arrest incidents for EMAS. VF, ventricular fibrillation; VT, ventricular tachycardia.

FIGURE 7.

Cardiac arrest incidents where a CFR arrived on scene before EMS. VF, ventricular fibrillation; VT, ventricular tachycardia.

Comparison of Community First Responder and ambulance outcomes

We compared outcomes for ROSC (Table 14) and 30-day survival (Table 15) using multivariable regressions models comparing CFR arrival before EMS with EMS alone for both using multivariable regression models. CFR attendance was not associated with higher ROSC or 30-day survival from OHCA.

Summary

Community First Responder attendance before the ambulance arrived was not associated with improved ROSC or 30-day survival outcomes from OHCA.

Descriptive analysis

As a result of the recommissioning of the falls response programme (FRP), an important change in operation from the pilot stage was the replacement of the EMAS-owned BSVs with three similarly equipped LIVES-owned vehicles, their call signs being FRP1, FRP2 and FRP3. Operating with more vehicles had the effect of increasing in size the area that the FRP covered. In Figure 8, a heat density mapping of the incidents attended by each FRP vehicle is shown. FRP1 responded to emergencies mostly in and around Bourne and Spalding, occasionally attending as far afield as Louth and Mablethorpe. FRP2 responded mostly in and around Skegness, occasionally attending emergencies as far afield as Spalding and Long Sutton. FRP3 responded mostly in and around Lincoln but also attended calls in Gainsborough and Grantham.

FIGURE 8.

Heat density map of attendance by FRP vehicle. (a) FRP1; (b) FRP2; and (c) FRP3.

The heat map was derived from a total of 2090 incident attendances over the 21-month sample frame (April 2019 to December 2021), thus averaging 33.2 attendances per month by each LIVES CFR team. Further separation by urban–rural classification reveals totals of 1221 (58.4%) incidents in urban areas and 869 (41.6%) incidents in rural areas.

Using postcode data, Figure 9 gives the location of FRP attendances as well as indicating whether the patient had suffered a fall or had another type of emergency. Most incidents attended by the FRP, 1793 (85.8%) in total, were to falls patients, with the remainder to other types of emergencies, classified as non-falls. Among falls patients, the urban–rural split of incident location was urban (57.2%) and rural (42.8%).

FIGURE 9.

Falls response programme incident attendance by falls and non-falls.

In addition to emergency type, call category was another determinant of whether a falls patient could receive treatment in accordance with the FRP protocols. In Figure 10, attendances to falls patients by the FRP service are displayed by severity and separated by whether FRP protocols were followed (left panel) or not (right panel).

FIGURE 10.

Call severity of falls incidents. (a) Protocol followed; and (b) protocol not followed.

Category 1 life-threatening falls were ineligible for FRP treatment, but this did not exclude EMAS dispatching the FRP to an incident of this severity. The FRP vehicles were dispatched to attend 44 category 1 falls, locations of which are shown in Figure 10b. On the other hand, FRP treatment could be administered to falls patients classified category 2 or lower, but the right panel shows that many (n = 227) were not treated in accordance with FRP protocols.

The FRP protocol was followed in 1517 episodes of care (72.6% of all incidents attended; 84.6% of all falls incidences attended), where incident locations factored by severity call category are given in Figure 10a. Of these episodes, 812 (53.5%) were to calls located in urban areas and 705 (46.5%) in rural areas.

The locations of the 1517 incidents depicted in Figure 10a – those incidents in which FRP treatment was administered as per the FRP protocol – are replotted in Figure 11 classified by whether or not the FRP service was backed up by an EMAS ambulance unit(s).

FIGURE 11.

Ambulance unit backup.

The observed ambulance backup rate was 51.9% when patients were treated as per the FRP protocol. Of this group, 60.2% of incidents were located in urban areas and 39.8% in rural areas. In addition, for the group sent backup, 75.4% of patients were conveyed to hospital, while 24.6% were subsequently discharged at-scene.

Comparing the recommissioned with the piloted Falls Response Programme

For the pilot period of 7 months, 445 falls patients were treated as per FRP protocol by LIVES CFRs using a fleet of two BSVs, averaging 31.8 patients per month per CFR team. For the recommissioned FRP service, over 21 months 1517 falls patients were treated per protocol using a fleet of three vehicles, the average reducing to 24.1 patients per month per CFR team. The ‘gap’ between these averages was due to the use of FRP as auxiliary to the regular emergency services, involving dispatch and attendance at non-fall emergencies as well as life-threatening category 1 falls. Auxiliary use of the FRP was negligible over the pilot period but not so the recommissioned FRP, which was used in this capacity to the extent of, on average, 9.1 calls per month per CFR team.

Results from the pilot showed that the key driver of cost-effectiveness of the FRP over standard care given to category 2 or less falls patients was the rate of backup support required by the FRP. The backup rate observed during the pilot was 68% and for the recommissioned FRP it fell considerably to 51.9%. Our pilot economic modelling suggests that in this circumstance the recommissioned FRP may have the further advantage of being cost saving to the NHS (see Report Supplementary Material 3). 35

Summary

The falls response introduced as an innovation in one county enabled CFRs to attend people who had fallen, reduced ambulance attendance because only around half required an ambulance backup, and was potentially cost saving.

Content analysis

The content analysis involved examining keywords, phrases, topics and concepts in the policies and developed a coding manual using keywords from previously published studies of CFRs,3,18 expertise within the research team (GP, VHP, IT, NS) and an inductive approach to identify new keywords. We identified and analysed the frequency distribution of 37 keywords in 10 documents, ensuring that terms ending in -ance, -ed, -es, -ies, -ing, -s and -ship were included in the analysis (Table 16).

Our findings identified which and how often the keywords were used and distributed across included documents. Keywords such as ‘patient’ and ‘care’ were evenly distributed across the documents. The relative infrequency of phrases such as ‘rural’ indicated that rurality was not a focus of attention in the policy objectives. Understanding that certain keywords were more common in some documents than others and the changing of the dominating keyword across documents was the most significant finding.

The content analysis revealed the occurrence of keywords in the policy documents, but an understanding of the context was not established. Hence, we used discourse analysis to understand the contexts in which the keywords were used to relate to each other to form a discourse, as noted in the next section.

Findings

The overall discourse that emerged from the texts highlighted the objectives of CFR policies, which were to ensure benefits to the NHS and discussions on the usefulness of to the ambulance services. The governance mechanisms of the trusts were in accordance with legislation and the directives of the Care Quality Commission, the healthcare regulator. It was implicit in the documents that monitoring and compliance with government standards were essential for quality assurance. The findings revealed that the fundamental objective of the policies was to guide the CFRs in delivering high-quality care and facilitate trusts to provide quality assurance and demonstrate clinical governance, as demonstrated by the following excerpts:

The Care Quality Commission is an independent regulator of all health and adult social care services in England, to ensure that care provided meets government standards of quality and safety. The purpose of this framework supports the CFR contribution to meeting the aspects of care to ensure compliancy under the Health and Social Care Act 2012.

WMAS CFR Governance Framework v4.2 2018

CFRs play an integral role within SCAS, when attending emergency incidents within your local communities you will be providing emergency care and support prior to the arrival of our ambulance clinicians. The support you will be providing to your community is something that can’t be underestimated and subsequently, you will have been trained and given all the information you require to carry out this role. Thank you for joining us and we hope you enjoy responding with us.

SCAS CFR Handbook 2020

The Trust Board acknowledges the positive effect on patient outcomes achievable by a well-managed and effectively governed Community First Responder network, and is committed to providing support for this group of volunteers.

SECAMB Community First Responder Policy v0.2 2018

Discourse on Community First Responder roles and responsibilities

Community First Responders were specifically described as volunteers, regardless of whether they worked directly for the trust or indirectly under a local scheme, and throughout the documents a difference was maintained between trust employees and volunteers. Possible explanations include the contrast between paid and unpaid labour. In general, CFRs were seen as complementary and/or supplementary to the trust’s and NHS’s services and sometimes as volunteers who participate in the trust’s community involvement and outreach activities. Thus, CFRs were designed to bolster the NHS overall:

Volunteers provide a service to patients and their relatives. Their role is intended to complement NHS services and it is not intended that they will be used as a direct replacement for paid employment opportunities.

NWAS Volunteer Policy December 2019 v2.0

The Trust utilises Responders to supplement core ambulance resources. Responders are volunteers who have been trained to attend medical emergencies and deliver basic life support, oxygen therapy and defibrillation using an AED.

SWASFT Responder Governance Policy v9 2019

The role of the volunteer is to complement paid staff to enhance patient experience by undertaking specific tasks within clear role descriptions and guidelines. The role of the volunteer is limited so that it does not constitute paid work, and the time a volunteer is engaged in volunteering varies from an hour to several hours per week. Therefore, induction and refresher training should be at a level relevant to the CFR role.

WMAS CFR Governance Framework v4.2 2018

The CFR role in rural areas was not made explicit, although rurality was mentioned. Some documents acknowledged that it was essential to seek the assistance of CFRs to meet healthcare objectives in rural areas set by the government:

In line with the organisation’s mission statement: ‘To respond to patients, emergency and urgent care needs quickly and safety to save lives, relieve anxiety, pain and suffering’, South West Ambulance Service NHS Foundation Trust (the Trust) is committed to providing the population of the South West with the highest standard of out-of-hospital care. The Trust provides emergency care to around 2,500 people every day. All UK Ambulance Trusts have to respond to 75% of incidents triaged as potentially life-threatening, within 8 minutes. The enlarged organisation covers the largest rural area of the UK, providing ambulance services to a population which serves a resident population of over 5.3 million people, plus an estimated annual influx of more than 17.5 million tourists and covers almost 10,000 square miles, which is approximately 20% of the English mainland.

SWASFT Responder Governance Policy v9 2019

The CFRs’ responsibilities were set out in the various documents and included:

1. Complete a patient report form.

2. Familiarise themselves with the NHS Constitution and the trust’s core values.

3. Ensure that their behaviours reflect trust’s core values when they are undertaking voluntary activity and representing the trust.

4. Adhere to responsibilities set out in trust’s code of conduct.

5. Raise concerns.

6. Take account of the Working Time Directives.

7. Follow guidelines in policies relevant to the CFR.

8. Ensure that equipment is clean and in a serviceable condition when handing over.

9. Keep equipment and consumables safe and ensure the equipment is serviceable.

10. Inform the community and engagement training officer (CETO) through their co-ordinator when levels of medications are running low.

11. Use online communication networks sensibly and responsibly and consider the wider implications of using social networking sites.

12. Not to breach any confidentiality.

13. Ensure that they do not fall outside requalification period or be asked to stand down.

14. Report criminal charge or conviction immediately.

15. Be aware of their responsibilities towards consumption of alcohol and ensure that their alcohol level is zero.

16. Report any changes or endorsements to their driving licence.

17. Maintain their vehicle in a safe and roadworthy condition and ensure that it is sufficiently covered by suitable motor insurance and MOT (Ministry of Transport test).

18. Ensure that they produce their driving licence, MOT certificate and insurance certificate for ongoing checks.

19. Inform their insurer that their private vehicle is being used for a responding purpose and is liable for any claims when using the vehicle for responding.

20. Always adhere to the trust’s infection prevention and control policy and help ensure continued compliance of the trust with the Health and Social Care Act (2008).

21. Be responsible for providing their own defence at their own expense.

22. Comply with health and safety standards as set by the trust.

23. Not assess and leave patients on-scene without the clinical responsibility being taken by a responding clinician or a clinical supervisor.

24. Report if they are pregnant at the earliest opportunity.

25. Highlight any items requiring servicing prior to the expiry date.

26. Report any actual or potential incident using the trust’s incident reporting procedure.

27. Take sufficient rest and where relevant manage their normal employment commitments and their CFR voluntary time.

28. Follow the guidelines on attire for responding to minimise the risk of injury to themselves.

29. Raise with their local manager any perceived deficiencies or lack of contemporary experience in any practice area.

30. Ensure that the scope of practice is maintained.

31. Maintain sufficient fitness for their duties.

Discourse on Community First Responder structures

This section highlights the keywords examined in the documents and how CFR roles and responsibilities are structured and governed to meet the quality standard.

Summary

The NHS recognises the importance of CFRs to their local communities, and it was apparent from the documents that ambulance services invested substantial efforts to ensure that CFR programmes were effective, with procedures for recruitment, selection, training, support and monitoring. However, there are risks involved with the roles that CFRs perform, as they are individuals with (often) little clinical expertise who provide care to fellow community members voluntarily. Risks involved in CFR work include risks to CFR themselves, to patients and the public, and to the NHS ambulance trust that they represented. Ambulance trusts had established governance frameworks for checking compliance with frameworks such as rules, standards and procedures in order to mitigate risk. Variations in the frameworks create confusion that could interfere with regulatory body auditing programmes and the public’s perception of CFRs roles, and possibly discourage recruitment and retention of CFRs.

Participants

We conducted semistructured interviews with 47 different stakeholders engaged in the functions of CFR schemes, including CFRs, CFR leads, ambulance staff, commissioners of ambulance services and patients or relatives of patients who had received care from a CFR (Table 17). Most CFR leads were also ambulance clinicians. We recruited fewer patients and relatives (5/15) or commissioners (2/5) than we initially set out to, and the reasons for this are discussed below.

Themes

Findings arising from the empirical analysis are presented in the following three sections. The analysis identified different spheres of (A) varied experiences and determinants of CFR recruitment, training and retention; (B) CFR roles, governance, innovations and future opportunities; and the importance attributed to the notion that (C) patients are the reason for CFR schemes within the health system.

A. Varied experiences and determinants of Community First Responder recruitment, training and retention

The process of CFR recruitment was asked about and identified as a key theme in the analysis. The next section elaborates on the rudiments of CFR enrolment and addresses the study objective of eliciting the views of CFRs and CFR scheme organisers about the challenges in and solutions to recruiting, training and retaining CFRs in rural areas.

B. Community First Responder roles, governance, innovations and future opportunities

This section addresses the study objective of exploring the experiences and perceptions of stakeholders involved in the CFR schemes implementation on the CFR role, governance of CFR schemes, and the potential for further development and innovation of the CFR roles. The stakeholders were ambulance staff, CFRs, CFR scheme managers and commissioners.

Innovations already adopted by some Community First Responder schemes

Our findings revealed a number of innovations that had been developed and brought into CFR operations. These innovations originated at participating services, varied by ambulance service region, and were adopted by CFRs to various extents. In this section, we discuss the categories of the innovations and their attributes. The innovations included in CFR schemes were classified into two categories and five attributes (Figure 12).

FIGURE 12.

Attributes of innovations.

Role and skills innovation

The role innovation included the extension of CFRs’ scope of practice, for example the use of risers for lifting fall patients. Elsewhere, as part of the expansion of the CFR role, a group of CFRs with previous firefighter and police experience were granted permission to attend accident cases. Moreover, during the pandemic, the idea of modifying CFR responsibilities around social care was also put forward by commissioners:

Yes, we’ve got a couple in N, and they have been issued with a riser chair, and it’s basically a lifting device which can used by CFRs. Our conditions in the control room will look at the fall, patient stood on the floor unable to get up, they will follow a flow chart to see if CFR’s suitable to be sent … they can test the patient’s blood pressure, heart rate, etc., so that is a really good scheme.

CFR_BA_10032021

I think again in the P, just looking at the rural area, there have been trials of sending certain responders to road traffic collisions, again just because if it’s a nasty road traffic collision, these CFRs had to have some kind of previous knowledge … they previously worked for the fire service or the police, and that allowed them to be eligible to respond to these emergencies …

CFR_BA_10032021

The skills innovation primarily referred to the development and delivery of specialised training to CFRs so that they could undertake a specific set of roles and tasks. Some CFRs, for instance, had received specialised training to attend falls patients who had a low likelihood of sustaining an injury. New training for CFRs increased their ability to respond to these falls incidents, which fitted into the fundamental concept of CFR programmes, in which trained volunteers help those needing urgent care. CFRs also received specialised training in the use of risers when attending falls patients:

Patients will sit on floors for quite a number of hours, and they obviously tend to be older generation … and actually there’s potentially a CFR around the corner, that could go and help. Well, at the moment they were not allowed to move patients. So we are doing a trial in N … to improve that fall service, and education amongst our CFRs, so that they can go and assess non-injury falls, so that we can get some of these patients moved off the floor.

CFR_MW_09072020

Technology innovations

The ICT (information and communication technology) innovations referred to various innovations that were technological in nature. For example, CFRs used Google Maps to navigate to patients’ locations or houses, but the majority of dwellings in rural regions have names instead of numbers, making it difficult for CFRs to identify patients’ homes as Google Maps does not offer house names. In response to this issue, the ambulance service developed an application for use by the ambulance crew. Later, the same technology was also supplied to CFRs travelling to rural areas, and this innovation enabled CFRs to reach patients more efficiently. Elsewhere, another ambulance service used a similar communication device with live tracking, enabling the CFRs to determine the distance and arrival time.

Similarly, an electronic handover form was designed and implemented so that CFRs could share information with ambulance clinicians. Another ICT innovation was a radio with a panic button, which was issued to some CFRs to assure their safety and security for the challenging circumstances under which they often operated. The panic button was designed to be used in ‘hostile’ situations to alert the control room of a potential threat, and the control room would subsequently notify the police to ensure the CFR’s safety:

I would love to see CFRs issued with these radios because they have a panic button; so if you press the top it immediately alerts the control room to say there’s an emergency; and I’ve had a couple of risky situations before where a patient has turned volatile quite quickly, and it’s a bit rubbish trying to fumble through your pockets to try and get your phone out discreetly during the control room.

CFR_BA_10032021

The idea of the ambulance service assigning a specialised CFR vehicle for response purposes was an innovation in the transport attribute. The dedicated CFR vehicles increased the motivation of CFRs to engage by eliminating the burden of fundraising for the personal car insurance needed when using their own transport for the CFR role. Moreover, the dedicated car was believed to promote community recognition and identity, in the same way that ambulances are recognised:

We have a scheme car, like a marked ambulance car, that we use on our own shift, So I have a scheme car, I go on shift …

CFR_MM_30092021

The use of Entonox was a contentious topic in the scope of CFR practice, with some areas allowing Entonox to be used by CFRs and others excluding it from their scope of practice. As a result, the supply, training and use of Entonox was recognised as a health technology innovation:

So we are looking at … a business case has gone in, just before COVID around supporting CFRs having Entonox. An [ambulance service] leased or owned car, trying the use of Entonox. So we are at the point where we’ve got a train-the-trainer package being rolled out to our training officers, to deliver to those people it would hit as a trial. So it would be about 30 CFRs that will be getting Entonox before the end of the year. So if that’s successful then we can roll it out, and that will make a massive difference in the rural areas.

CFRLead_MW_09072020

C. Patients are the reason for Community First Responder schemes in the health system

Summary

Overall, CFRs and the CFR schemes were regarded as integral to prehospital care delivery by ambulance services. The CFRs were limited to their legitimate scope of practice, but stakeholders who participated in the study noted possibilities for role expansion. Ambulance services continually experimented with innovations and implemented them in the CFR operation through trials. The majority of innovations improved the coherence of CFR practice and the safety of patients and CFRs themselves. Moreover, ambulance services have long been involved in the recruitment and training of CFRs and have encountered challenges of workforce attrition.

Beneficiaries of CFR services, including patients, relatives and ambulance services, viewed the provision of CFRs as a safe, effective strategy while waiting for an ambulance. The assessment of patients’ conditions and the initiation of prehospital care were valued and reassuring to both patients and their family members:

None of [our] … CFRs have ever caused any harm to patients. We have had different things over the years with them but nothing that would cause harm to any patients.

CFRLead_CM_16112020

A landscape view of the CFR schemes might be interpreted as a top-down policy implementation of prehospital care delivery utilising trained community volunteers, in contrast to a bottom-up approach with community engagement in health services.

Integration through design

The study design required the collection and analysis of quantitative and qualitative data together, which allowed multiple points of integration throughout the study.

For example, quantitative data on incidents at the six ambulance services provided data for the cross-sectional studies, but the initial data analysis allowed us to identify a random sample of 100 patients, CFRs and ambulance staff for incidents in rural locations together with demographic information on patients attended and other details of the incident, which enabled us to contact participants for interview through the ambulance services. Unfortunately, we were able to identify only one triad of patient/relative, CFR and ambulance staff member using this method because of a lack of response.

The cross-sectional studies largely preceded the qualitative interviews, which allowed further integration. For example, the quantitative analysis showed that CFRs had a higher rate of attendance at incidents in rural areas, and were less likely to attend patients from minority ethnic backgrounds or from more deprived areas, or younger people (aged < 39 years), allowing us to explore possible explanations for these differences in the interview study.

The results of the earlier cross-sectional and qualitative studies were presented at the consensus workshop and informed the list of CFR innovations and subsequent discussion and voting.

Integration through analysis

The organisational context in which CFRs functioned was described in the documentary analysis. This showed how participating ambulance trusts sought to ensure that CFRs maintained high-quality, safe, effective, efficient and equitable practice that was closely incorporated into the wider operations of EMS.

The quantitative analysis provided additional context, showing that CFRs attended a greater proportion of incidents in rural areas. The quantitative analysis also showed the benefits of CFRs attending in terms of a more rapid response to incidents, particularly in rural areas, the earlier response being welcomed by the patients and their relatives interviewed as providing reassurance and enhancing their experience of care. The innovative CFR response to falls in one county, which often did not require ambulance backup, provided a possible explanation for the reduced conveyance rate associated with CFR attendance. The finding from the quantitative analysis that CFRs attended people with cardiorespiratory and neurological and endocrine conditions but that they also attended those with a wide variety of other conditions matched the wide variation and type of incidents that CFRs in interviews reported being dispatched to, including lower-acuity problems such as falls.

We interviewed the main actors involved, including patients, relatives, the public, CFRs, CFR leads in ambulance services and charities, ambulance staff and commissioners. Although these stakeholders were identified at the outset, their perceptions of CFRs, learned through the interviews, the relationships between them and the similarities and differences of their views on the current and future role of CFRs and how this should be developed were assimilated with the quantitative findings to inform an actor-based system map (Figure 14).

FIGURE 14.

Actor-based system map for CFRs’ role in the current and future rural health and care workforce.

Participant interviews revealed the trajectory or course by which volunteers joined and continued (or left) their role as CFRs, describing their delivery of services to patients and the perceptions and recognition of their identity as members of the rural health care workforce by community members and health professionals. Different actors were also able to provide insights, from interviews, into areas that had been explored in other aspects of this study, such as CFR policies and governance (in the documentary analysis), workforce and training, and recruitment and retention (in the resource and workforce survey). They were also able to describe a wide range of innovations that had already been introduced in some areas, as well as others that were being considered, for discussion and ranking in the consensus workshop. The interviews also provided information on the changes to processes and structures needed to address the barriers to CFRs operating in a rural community context as displayed in the actor-based system map (Figure 14). The relationship between quantitative and qualitative findings described above is summarised in Table 18.

The interviews and consensus meeting also allowed us to consider the causal impact pathway by which behavioural change could be brought about, the theories of action (pathways and interventions promoting actor-level change) and the theory of change (i.e. the ways in which actor-level changes could lead to systems changes and impacts). 38 This included engaging with stakeholders to engender greater ownership of change, understanding innovations from the perspective of different stakeholders and involving a wide range of actors in a consensus meeting to prioritise innovations.

Summary

The integration of quantitative and qualitative data was achieved through both research design and data analysis, allowing us to triangulate findings and develop an actor-based system map of the CFR role, function and meaning and a classification of future innovations.

Participants

A total of 26 participants participated in the consensus workshop. This comprised 11 ambulance services representatives from all 6 participating ambulance services and one other, 6 patient panel members and 9 researchers from the research team.

Innovations

The list of ideas and innovations identified from the empirical findings and introduced at the consensus workshop is noted in Box 2.

In session 2, consensus participants were divided into two online groups and one face-to-face group. During the session they generated and discussed additional round-robin ideas on innovations. In Box 3 we list the innovations discussed in the three groups.

When the session finished, all the innovations presented, generated and discussed were collated and entered into the JISC online survey. Innovations were prioritised using a Likert scale of 1 to 5, with 1 representing ‘not a priority’ and 5 representing an ‘essential priority’. One survey was administered during session 3 of the consensus workshop, followed by a discussion of its findings. The survey was administered for a second time, at the beginning of session 4, after which there was further discussion.

Qualitative results

The qualitative results provide important context for understanding why some innovations were prioritised over others.

For example, the importance of counselling particularly following difficult or traumatic incidents in the isolation of working as a CFR was emphasised:

The need for counselling [is important]. We are lone people, and believe you and me, as a community responder, I’ve now dealt with three people that I knew who’ve died of a cardiac arrest. Yes, [being a] CFR can be lonely, and I think that, in fact, it should be standard practice that after any CFR has dealt with a cardiac arrest where the outcome has been death, there should be an automatic phone call to that responder to help support them. Crews can support each other, CFRs can’t.

In addition, the notion of peer support as distinct from professional counselling for CFRs was debated and discussed:

The consensus around debriefs after critical incidents and trauma is that the most important thing is actually the peer support that is available for emergency services. So, I think the emphasis should be on peer support, and that has the advantage – which is linked to the community – of being non-professional and it’s provided by others who know intimately through their own experience what it’s like to deal with these critical incidents and to live in certain communities, and so it de-professionalises it …

Information technology to help CFRs locate incidents, communicate with ambulance services and ensure their safety was highlighted as being important:

A contemporary navigation map helps CFRs to find the location of patients easily, especially in remote and rural areas. The navigation map highlights the name of the house, as well as automatically navigate the CFRs to reach the patients.

A radio with a panic button, is a significant innovation for ensuring safety of the CFRs, which would be used in hostile situation. For example, there was an incident where a CFR was held hostage and in that situation the CFR tried to call the control room asking for help, but the call was missed. So, having a radio with a panic button will help to improve the security of the CFRs in such situations.

Training relevant to the CFR role was another area that was considered essential for maintaining high-quality care:

As a responder, I’m being given training in child abuse. I don’t think that giving me an hour’s course on child abuse gives me the right to make those kinds of judgements. So, I think we need to make sure that training is very, very relevant. To give a CFR fire training on evacuating patients from hospital is totally irrelevant, but I had to do it to stay as a CFR. So, we really do need to consider that.

National standards for training were felt to be helpful for ensuring quality of care:

There should be national standardisation so people can move around, and so the public knows that when a CFR attends, they’ve had some sort of training. But the roles should be defined, because there are a lot of CFRs that do only want to operate in their own community, and there are some that are looking at it as a progression to another career.

The national standards would also increase the transferability of training from one region to another:

In terms of portability within services, in-house training courses mean nothing to anyone else. When you move an internal certificate to another organisation, it doesn’t mean anything. Actually, that portability level helps with some of our recruitment and retention.

Creating greater awareness of and promoting CFRs in the community was offered as a way of address the general public’s lack of knowledge about CFRs, but it could also improve CFR recruitment and retention:

You need to be reaching out to the community … There’s a lot of willingness, I think, in the community to help out, but somebody has to be set up to actually help us as community members get involved, get trained and start doing things that are useful.

Although there was some support for activities such as CFRs transferring patients to hospital, this was seen as giving rise to potential risks for patients and CFRs:

The CFRs should be able to transfer the patients to nearby hospital particularly in remote areas where ambulance arrival time is more than 30 minutes. And that would also reduce the cost of patient transfer as compared to allocation of an ambulance.

After discussion, some innovations, such as emergency ‘blue’ lights for CFR vehicles, were considered less important:

Data suggests that the CFRs should be able to use a blue light, which will enable CFRs to reach patients early, while getting around traffic and delays. On the other hand, some suggest blue light access for all CFRs might pose a risk for the CFR themselves as well as others on the road since it requires a high level of driving skills.

Another aspect of the discussion was the need expressed by one participant for greater clarity of the CFR role:

There becomes a point where we actually need to go back to basics and ask ourselves what the role is about and what we’re wanting them to achieve. Do we want our CFRs to go to category 1 calls? Do we want them to go to category 3 and category 4 calls? Do we want them to go out and man welfare stations? What is it that we’re wanting from our four or five hours a week?

This was also expressed as a tension between the desire among some stakeholders to innovate and the feeling, particularly among some CFRs, that they wanted the role to remain focused on prehospital emergency care, which is why they had joined as volunteers:

There is an ongoing persistent concern about expanding the CFR role, and [recommended that] the CFR role should be maintained in its current form.

Survey results

A total of 17 consensus participants (i.e. excluding research team participants) took part in the first survey, and the results of the prioritisation revealed that the requirement for communication gadgets with live tracking, national minimum standards, standardised training, an increased number of volunteers, counselling support for CFRs and peer support were prioritised as essential. All these innovations had a median score of 5, indicating that all respondents classed them as being ‘essential priority’. By contrast, innovations such as CFRs attending road accident cases, CFRs’ access to blue lights and patient transfer to hospitals were given the lowest priority, all having a median of 1, which indicated that all respondents regarded them as ‘not a priority’.

Sixteen consensus participants participated in the second survey, and the results indicated that the innovations considered to be essential priority were communication gadgets with live tracking, better communication with the control room, creating awareness and promoting CFR in communities, standardised training, mandated and specific training for CFR, counselling support for CFRs and peer support. The innovations categorised as not a priority were the same after both rounds, and these included CFRs’ access to blue lights and patient transfer to hospital by CFRs.

The comparison of the priorities in round 1 and round 2 showed that the following innovations increased in priority: having a dedicated car for CFRs, a requirement of electronic handover form, the future roles of CFRs attending road accident cases, the future roles of CFRs attending falls patients using risers, use of GlucoGel (Venture Life Group PLC, Bracknell, Berkshire, UK), a system of creating awareness and promoting CFRs within the communities, the requirement of national volunteer certificate training to specify a few. There were also innovations that decreased in priority after discussion, such as CFRs having a social and public care role, CFRs working as a dual crew, termination of resuscitation guidelines and receiving more funding support from ambulance services. Table 19 shows score differences and priority of innovations comparing rounds 1 and 2.

Summary

The consensus process led to a prioritised set of innovations for future roles of CFRs in rural emergency care provision. The prioritisation of innovations reflected the prospects for the future development of CFR schemes based on the experiences of patients and the public, CFRs, ambulance clinicians and ambulance service leaders.

Emergency calls attended by Community First Responders

The cross-sectional study was the first to our knowledge to provide an exhaustive, quantitative analysis of the number, rate, dispatch conditions, urgency, location and characteristics of patients attended by CFRs. 42 This offered a widescale analysis investigating the contribution of CFRs to EMS, and showed that CFRs attended first a higher proportion of calls in rural areas (almost 4% of total calls) than in urban areas (around 1.5%) in six English regional ambulance services in 2019, before the COVID-19 pandemic.

Community First Responders attended all call categories but mainly the most urgent categories (categories 1 and 2), which included 83.7% of all CFR first attendances. CFRs attended patients with a range of dispatch conditions, but the most common categories were cardiorespiratory (30.2% of CFR attendances), injury and trauma (20.1%), and neurological and endocrine (13.4%). Compared with attendance by ambulance service staff, CFRs were more likely to attend cardiorespiratory and neurological and endocrine conditions and less likely to attend injury and trauma, gastrointestinal, urinary, psychosocial or palliative conditions. Conveyance to hospital was around 2% lower when CFRs were present on scene.

The multivariable logistic regression model confirmed that CFRs were more likely to be called out to rural (compared with urban) areas. The calls where CFRs were in attendance were more likely to involve older, white people in more affluent areas with cardiorespiratory and neurological conditions as emergency or urgent calls.

Resource use and allocation

To the best of our knowledge, the survey and analysis of resources used, how these were allocated and the CFR workforce in five of the six participating ambulance services was the first of its kind. Although CFRs are largely unpaid volunteers, they incur costs for the ambulance services and charities that support them. Resource data were incomplete because they were neither collected nor available in some cases because CFR costs were not disaggregated from other ambulance service costs. Costs varied widely (around 20-fold) between ambulance trusts, partly because they were incomplete, ranging from £40,000 per year to over £800,000. The costs were attributed to staff providing management, organisation and training together with non-pay costs such as equipment and reimbursement of out-of-pocket (fuel and vehicle use) expenses.

Where recorded, CFRs worked on average around one shift per week for around 7 hours, and they were distributed in both rural and urban areas, varying according to ambulance service, with CFRs in some ambulance services predominantly rurally located and others mainly operating in urban settings.

Outcomes of Community First Responder attendance

We investigated CFR outcomes for timing of attendance, and OHCA as well as the CFR falls intervention in Lincolnshire. CFRs provided a clear time benefit in terms of achieving response time targets and earlier attendance at incidents, particularly in rural locations. CFRs were also able to respond to people who fell, particularly when those people were not injured or unwell, and no ambulance backup was required in around half of the falls incidents attended. Economic modelling suggested that this was likely to be cost saving to the NHS. 35 Finally, we did not find any clear benefit or disbenefit to OHCA outcomes when CFRs arrived before ambulance staff.

Discourse analysis of Community First Responder policies and protocols

The analysis of CFR policies and protocols, to our knowledge the first on this subject, revealed the extent to which ambulance services invested efforts to ensure that CFR programmes were integrated into ambulance service structures, enabling them to operate effectively and safely. 52 This also revealed risks associated with volunteer roles and how these were mitigated. The risks, which included risks to CFR themselves, to patients and the public, and to the ambulance service, were addressed through policies that enacted governance frameworks to ensure compliance with rules, standards and procedures. These operated from selection and recruitment through to training and operation to termination of the role. The variation in these frameworks across services, which could create confusion for commissioning, regulatory oversight and public understanding of the CFR roles, could also affect the recruitment and retention of volunteers.

Stakeholder perspectives

Interviews with patients, relatives, CFRs, CFR leads, ambulance staff and commissioners across five ambulance service regions ensured that perspectives from a wide range of stakeholders were considered, providing the largest study of its kind. 66 We recruited fewer patients and relatives or commissioners than we initially set out to, which means that findings from these groups need to be interpreted with caution, and the reasons for this are discussed below. The original contribution of this study is the identification of a set of inter-related CFR practices in facilitating timely prehospital care delivery and patient transfer. This study also contributes to the understanding of different CFR roles and the rural context in which they operate. From a focus on disease-specific CFR roles,9 this study expands the CFR discourse to include the CFR functions in broader prehospital and social care provision.

Community First Responders were motivated by their interest in engaging with their local community to provide urgent care, particularly in more remote areas where ambulance services were less easily accessed. This posed problems for recruitment in sparsely populated areas, which was exacerbated by the availability of mostly retirees and an older volunteer workforce compared with urban locations. Recruitment, support and training were often lengthy processes but needed to develop an effective volunteer workforce. There were many factors, such as conflicting pressures or priorities, mismatch between expectations and the reality of the CFR role and changes in the role and the effect of the pandemic, which affected retention.

Community First Responders’ actions were important in bridging the gap between the emergency call and the arrival of ambulance clinicians by providing early assessment and intervention (Figure 15). Receiving an alert from the ambulance control and obtaining initial patient information paved the way for the next stage of reaching patients. The CFRs’ response started with the acquisition of further patient information and validation of the information from the control room. The CFRs exchanged complete and precise patient information with the control room for triaging and to update the responding ambulance clinicians so that they were more prepared on arrival. The CFRs provided a rapid emergency response, including CPR and defibrillation, and the final step was to engage with ambulance crews to expedite patient transfer and minimise transfer time. Thus, CFRs performed vital emergency healthcare practices, particularly for life-threatening conditions, by delivering direct or indirect care interventions. These actions were especially important when the ambulance’s arrival was delayed.

FIGURE 15.

Conceptual map of CFR practices.

Innovations included changes in processes and structures (Figure 14), for example expansion in the CFR role and scope of practice, skill development for attending new types of emergencies such as falls or road traffic collisions, ICT applications for communication with ambulance call centres and staff or navigation to incidents, specialised vehicles and the availability of new treatments, including for pain management.

Other aspects raised included the importance of psychological support, good workforce management and communication to ensure adherence to policies, and the need for volunteers to raise funds for equipment and running costs.

The scope of practice of CFRs differed from one ambulance service to another, but there were indications that the role had already developed significantly into new areas, such as attending people who had fallen or road traffic collisions, and suggestions by some, but not all, stakeholders that new roles, for example in social care, should be considered.

Finally, patients and their relatives who had been attended by CFRs were overwhelmingly positive about the response and care they received, and the reassurance of a timely response from someone with expertise arriving in advance of an ambulance clinician, but this contrasted with a perceived lack of awareness about CFRs and their role among the general population.

Priorities for innovation in the rural Community First Responder workforce

The mNGT, used as part of a consensus workshop, allowed us to reflect on the research findings, introduce new areas for improvement and discuss these ideas for innovation with a wide and informed stakeholder group, which included public contributors, CFRs, ambulance leaders and staff from all six ambulance services and regions.

The areas that were most highly rated after two rounds of voting were counselling and support for CFRs, peer support and hot debriefs, better communication from and with the ambulance control room (or EOC), together with navigation and communication equipment, specific mandatory and standardised training for CFRs, and creating awareness and promoting CFRs in the community and among the general public.

Research team

Our research team was interdisciplinary due to the complex nature of the work and the importance of public contributors and wide expertise including knowledge of ambulance services, primary care, data management, statistics, sociology, econometrics, health economics and mixed methods. The chief investigator and 7 other co-authors were from a minority ethnic group, and 5 of the 15 were women. One member of the team went on maternity leave and returned before the completion of the report after having her baby. We included team members with disabilities. We had five early career researchers in the team, all of whom played an important role in the study, leading on key areas of the work and on authoring publications arising from them, while being supported by senior members of the team.

Public contributors

We successfully expanded our public contributors on the study, as described above (Patient, public and wider stakeholder involvement), from our two lay co-applicants and steering group members to a panel of seven patient and public representatives, through which we were able to ensure geographical representation from all participating ambulance regions, covering most of England, with lay members of different sexes, ethnic minority statuses and with and without disabilities. 65 Their contributions were essential and are described in detail below.

Data

We used routine data sets from six regional ambulance services, which included details of patients’ clinical conditions, age group, sex, region, ethnic minority status and socioeconomic deprivation, as a result of which we were able to include a wide range of participants in our analysis, reflecting people attended by ambulance services and CFRs. 65 The statistical models were also able to take these factors, where relevant, into account in our analyses.

Interviews

We sought to recruit widely for the interviews of patients, relatives and ambulance staff, using different methods including ambulance records, ambulance service CFR and research leads and their teams, and social media. To ensure inclusivity in interviews, we identified a random sample of 100 records of patients attended by CFRs in a rural setting in the previous 6 months using the quantitative data provided by all six ambulance service regions. Patient data included age group, sex, ethnicity67 and socioeconomic status, allowing us to sample across all these demographic characteristics using maximum variation sampling. Ambulance staff were also recruited for differences in sex, experience, ethnicity and role, and CFRs for differences in sex, ethnicity, length of experience and skill level. 68

Public contributors

Public contributors included two co-applicants who were members of the study steering committee, and another who was a member of the study oversight group and a PPI panel. The panel included two male (and five female) participants, three participants from minority ethnic groups and one participant with a disability. It also included one member who was a CFR. The lived experiences of this group were instrumental at various stages of the study. The panel members met on two occasions to provide views at the initial design stage and on the findings. Members were also invited to the consensus meeting, and six attended.

The public members provided advice on and input to the overall study design, development of study materials, analysis and interpretation of the findings in each work package, through membership of the study steering groups, oversight group and patient panel. The panel helped formulate recommendations and advised on the content and mode of delivery of study outcomes to lay audiences. Their role in shaping the overall direction of and output from the research was critical in ensuring that our approach was sensitive to and grounded in the needs of the wider community that the research may influence.

Validity and methodological rigour

Members of the PPI panel were presented with emerging findings from the study on the activities, operations and practices of CFRs. We found that these meetings supported the research process through discussions about the social reality of CFR functions from members or their relatives who had received or provided care (one member was a CFR). These meetings with PPI members were important for validating the data and the subsequent interpretation.

Patient and public involvement member P asked how the CFRs and ambulance can communicate better because local (CFRs) would know how to get past a road closure, and ambulance arrival could be faster. PPI member M mentioned a sophisticated communication system using mobile phone/satellite navigation, which logs the call as it happens and navigates to the patient’s location while avoiding road closures. A researcher then confirmed that these types of equipment were not universal and that they differed between ambulance services. The research team agreed that the differences in innovations between the ambulance services would be explicitly noted and explored further.

Thus, the PPI helped the establishment of internal validity in the CFR study. The contributions of the PPI participants were not limited to the qualitative methods but also included the quantitative component. For example, PPI member M commented on the number of trauma calls, as this was larger than they had expected. A researcher explained that, for the purposes of the study, this category was very broad and included falls of different types as well as injuries other than serious trauma. They agreed that these different types of injury could be separated out.

The understanding of public contributors helped to achieve validity and methodological rigour.

Roles in achieving consensus

The PPI panel members participated in the consensus workshop and actively contributed to the production of ideas and innovations, as well as their prioritisation. An important contribution to the discussion of innovations was around the challenges for CFRs in navigating remote locations and the safety of CFRs. The conclusion of the consensus workshop emphasised the requirement for an improved navigation system and the development of national standards.

For example, during the consensus meeting a public contributor stated:

It’s important that there are national standards across the ambulance trusts to make sure CFRs have all got the same opportunities, i.e. best practices. So, in areas that have best practices, they ought to be rolled out to other areas. There need to be national standards, not only in terms of the CFR role and all the role’s different variations but also as far as recording things and making sure of that in future monitoring.

AB_05052022

The public contributors fully engaged in the research process and represented a range of public perspectives.

Proportion of Emergency Medical Services calls attended by Community First Responders

Previous research emphasised the positive role and potential for CFRs in complementing the work of ambulance services, particularly for rural emergencies, but their contribution has not been well described before. 3 A finding from the previous study in 2007, suggesting that CFRs attended around 2% of all calls,1 was confirmed in this study, but we also found that the proportion was double this in rural areas.

Types of clinical conditions attended by Community First Responders

We found that CFRs were sent to people with a wide variety of conditions, but they predominantly attended the most urgent call categories 1 and 2. CFRs in all six services in this study were dispatched to people with illnesses other than cardiovascular disease and trauma, including neurological, endocrine, gastrointestinal, urinary, psychosocial and end-of life conditions, which suggests that they are being dispatched by UK ambulance services to people with a wide range of conditions. This suggests that CFRs were not restricted to responding to calls from patients with chest pain and cardiac arrest, as was the case in some services over a decade ago. 1 However, they do attend, in larger proportions than ambulance staff, calls from people with cardiorespiratory (breathing problems, chest pain, stroke) and neurological (loss of consciousness, convulsions, collapse) or endocrine (hypo- or hyperglycaemia) conditions.

Equity of Community First Responder care to different population groups

Community First Responder attendance was less likely for younger people, those from ethnic minority groups or those living in more deprived areas than for older, White British people living in more affluent areas. Although this partly reflects the rural population, which overall is older, less deprived and less ethnically diverse,69,70 the results remained the same even after controlling for rurality in the multivariable logistic regression model. People attended by CFRs are likely to be characterised by complex inter-relationships between patterns of population morbidity, help-seeking behaviour, access to services, and the location, availability and dispatch of CFRs, which may be different in rural areas. 71 These differences area likely to vary by country, region and CFR scheme. In one study of CFRs attending OHCA in Ireland, CFR schemes were more likely to be centred in areas of higher deprivation, but beyond a catchment of 4 minutes there were no differences in area-level deprivation of incidents attended by CFRs. 72 Some CFR schemes, for example medical student responder schemes, run through a number of English medical schools and operating under the auspices of ambulance services in England, are largely based in urban areas and because of this are more likely to attend patients of white ethnicity than other CFRs and ambulance staff alone, and more likely to attend incidents in areas of higher compared with lower socioeconomic deprivation. 73

Costs, resource use and outcomes

Costs varied widely between ambulance services, as did the numbers in the CFR workforce and what resources were used for, including CFR management, training, equipment and fuel, but the analysis was hampered by incomplete data.

Previous research has identified that the commitment of resources to support volunteers is key to ensuring volunteer goodwill, engagement and retention and that strong management support, communication, training, equipment and out-of-pocket expenses are essential human and physical resource requirements for maintaining a CFR workforce integrated with ambulance services. 74

Previous studies have documented perceptions among experts that a CFR response could improve outcomes but also highlighted the need for more evidence on outcomes of the CFR response, whether from the perspective of the patient, CFR, ambulance service, commissioner or researcher. 3,75 Although studies have investigated the impact of lay responders on OHCA (see Out-of-hospital cardiac arrest survival)10 or trauma,16 this study documents the wider benefits of CFRs attending.

Response times

Community First Responder attendance was associated with a shorter response time and greater likelihood of achieving response time targets than ambulance response alone, a difference in response times that was greater for incidents in rural areas. CFRs were more likely to arrive more quickly than 15 minutes (compared with 15–20 minutes), which was expected given the more urgent nature of the conditions that they attended, but they were also more likely to arrive at incidents later than 20 minutes, which indicated that they were also being directed to less urgent cases when ambulance crews might have been delayed attending, such as falls. In one previous small-scale study of an inner-city medical student CFR scheme in which 89 emergency calls were attended alongside West Midlands Ambulance Service, the mean CFR response time across all calls was on average 3 minutes and 8 seconds faster than ambulance crew response times, with the greatest difference in response time (12 minutes) for calls related to falls. 28

Out-of-hospital cardiac arrest survival

Community First Responder attendance was not associated with improved ROSC or 30-day survival outcomes from OHCA in our analysis. This is in line with previous rigorous studies but at odds with evidence from other observational studies.

In a Cochrane review of RCTs and quasi-randomised control studies investigating the effect of CFRs dispatched to OHCA in adults and children (older than 4 weeks of age), comparing CFRs combined with EMS versus EMS alone, in terms of survival and neurological function, there were two completed studies meeting inclusion criteria comprising a total of 1136 participants. 32 One, a cluster RCT of 469 adults with a witnessed OHCA, conducted in Amsterdam, Netherlands, during 2000 and 2002 and investigating police and fire service first responders equipped with AEDs, found no difference in survival at hospital discharge (OR 1.3, 95% CI 0.8 to 2.2), despite all 72 incidences of defibrillation performed before EMS arrival occurring in the intervention group and even though the study reported increased survival to hospital admission in the intervention group (OR 1.5, 95% CI 1.1 to 2.0). 76 The other was an RCT conducted in Stockholm, Sweden, between 2012 and 2013 investigating the dispatch of nearby lay volunteers to witnessed and unwitnessed OHCA in adults and children aged ≥ 8 years in addition to EMS responders including ambulance, police and fire services, which found no difference in 30-day survival (OR 1.34, 95% CI 0.79 to 2.29; 1 RCT; 612 participants) despite a significant increase in CPR performed before EMS arrival (OR 1.49, 95% CI 1.09 to 2.03). 10 Neither study assessed neurological function or health-related quality of life at hospital discharge or at 30 days. The overall certainty of evidence for the outcomes of included studies was low to moderate. The review authors concluded that there was moderate-certainty evidence that CFR interventions resulted in increased rates of CPR or defibrillation before EMS arrival but no evidence that this translated into improved survival. 32

One explanation could be related to timing and rates of defibrillation. When comparing CFRs carrying mobile AEDs and fixed PADs, more shocks were delivered by fixed PADs and outcomes were better than with mobile AEDS carried by CFRs. Most (over 85%) OHCAs occur at home,29 and people the affected tended to be older and with unwitnessed arrests, who therefore receive fewer shocks and experienced greater delays in starting CPR and attaching an AED. 77

The lack of evidence from improved OHCA contrasts with the finding using registry data that European regions that dispatched lay and professional first responders showed higher ROSC and survival rates than regions without. 78 Technological innovations for CFRs such as text messages79 or Global Positioning System applications have been found to be associated with earlier response times80 and defibrillation, with a small study on a rural island even showing good survival outcomes. 81

Reduced conveyance to hospital

Community First Responder attendance was associated with a small (around 2%) but still significantly lower conveyance rate, a finding at odds with their attendance at people with more urgent conditions who were more likely to be transported to hospital. Possible explanations include CFRs also attending low-risk incidents such as falls where an ambulance response, following advice from a health professional, is not always deemed necessary, as found in the FRP, or that the most urgent cases were associated with higher death rates and therefore those people who died were not conveyed to hospital. However, this result should be interpreted with caution as only qualified ambulance staff convey patients, and the differences in rates were small.

Patient and family experience

Community First Responder schemes and the role of CFRs contributing to the delivery of emergency care in rural regions were linked to patients and their family members reporting feeling reassured by the presence of CFRs, despite a lack of awareness of CFRs in their communities. Positive patient and family experiences accorded with expert opinion that community first response can be an important source of support and comfort for patients’ relatives. 75 The reassurance of a CFR arriving quickly and providing initial assessment and treatment before handing over to a clinician was an important outcome, and was similar to that provided by ambulance staff, where a short wait for help, good communication, professionalism and continuity provided confidence to patients and their relatives. 47

Personal and community engagement and resilience

The findings from this study were consistent with those of other studies demonstrating that a key determinant of becoming a CFR was the desire to provide a service to and engage with the community, but that other factors including previous experience observing a CFR attending an emergency or cardiac arrest, experience as a healthcare worker or the potential for learning and future work in EMS were also motivators for some. 3,9,82 These motivations aligned with the first four motivations of functional theory developed by Clary et al. 5 which include individual values, seeking understanding through learning or skills development, enhancement though psychological growth and career progression.

In a mixed-methods study, a questionnaire survey to emergency response volunteers in China found that participants were more willing to volunteer if they resided in rural areas, had stronger community bonds and felt responsible to contribute, but interviews revealed that they were less likely to volunteer in the context of a poor policy environment (lack of funding, regulation or co-ordination) or programme management (recruitment and training). 83

Motivations were assessed during recruitment and previous experience during training and allocation of roles, while management support was seen as important to ensure that functions were carried out safely and effectively and that CFRs could be maintained in their role. These aspects have been found in previous studies to be vital to successful volunteer programmes. 84 We found that changes in personal life and circumstances, as well as the challenge of committing time alongside concurrent employment or conflicting priorities, were the primary reasons trained CFRs left the workforce.

The psychological impact of being a CFR and the need for psychological support has been identified as being important in other studies,75 with CFRs shown to be affected by stress through frustration at not being able to help more, struggles with emotional or mental health demands, or the loneliness of the CFR role. 20 By contrast, the relative resilience of lay responders, even in high-stress situations such as cardiac arrest85 or mass terror incidents,86 has been observed. A phenomenological study87 found that a realistic understanding of limitations, confidence in skills, the ability to handle positive and negative outcomes, and a degree of emotional detachment enabled CFRs to function in stressful situations without experiencing negative psychological consequences, and these attributes might be considered when recruiting volunteers to this role. A questionnaire study85 comparing volunteers who had been exposed to stressful mass terror incidents with those who had not found higher but subclinical rates of post-traumatic symptoms and positive effects on self-efficacy among the former.

The operations of CFR schemes and the practices of CFRs within rural communities were aligned with the concept of community resilience,88 whereby it can be argued that CFR schemes, as an effort to include communities in rural health care, were framed as enhancing a community’s ability to cope with and respond to the requirement of rapid care for patients who seek EMS. 75,89 The CFRs played an important bridging role in ensuring the resilience of the community. 22

Relationship between ambulance staff and volunteers

Although we found many examples of positive and collaborative relationships between CFRs and ambulance services, this and previous research has also found ambivalence in the relationship. In this study, we found that ambivalence arose from perceptions of communication, role, accountability trust and of CFRs being valued (or not) by ambulance staff. 3,18 A focus group study exploring conflicts between volunteers and paid staff in a non-profit organisation in Madrid, Spain, found tension arose because conflicts in tasks, processes and relationships were more important than differences in status, with greater levels of conflict in paid staff than volunteers. 90 A survey study exploring the differences between paid employees and volunteers found that while fair task division and minimising role overlap reduced tension in both groups, staff focused on task- and process-related approaches to managing interactions whereas volunteers valued relationships and feeling appreciated. 91 This finding provides insights into ways of improving the relationship between these groups.

Governance of Community First Responder schemes

Governance structures including policies, guidelines, protocols and systems for recruitment, management and training together with the need to ensure compliance with rules, standards and procedures provided the means to integrate CFRs into ambulance service structures and to ensure their effective and safe operation, while mitigating risks to patients and the public, to CFRs, and to the ambulance service. These structures aligned with best practices for public sector volunteering92 and to varying degrees aligned or were at odds with factors that aided integration with ambulance services, as discussed below. 74

Factors encouraging the integration of CFRs into ambulance services were investigated in a study involving surveys and interviews of senior managers responsible for ambulance volunteers and first responders from Australia and New Zealand, which found that commitment to a volunteer model, leadership, good communication, shared protocols, appropriate resources and rewards, and relative autonomy of CFR schemes were considered important. 74 The relative autonomy of CFR schemes is realised by some large charitable and independent schemes such as LIVES, but this is less apparent in many schemes run by ambulance service.

Community First Responder schemes in themselves are relatively innovative aspects of the healthcare system and EMS. There is a perception among managers and experts, at least in the Antipodean context, that many innovations have taken place in CFR schemes but remain unevaluated or unpublished. 74