Authors' objectives: Community First Responders are trained volunteers dispatched by ambulance services to potentially life-threatening emergencies such as cardiac arrest in the first vital minutes to provide care until highly skilled ambulance staff arrive. Community First Responder schemes were first introduced to support ambulance services in rural communities, where access to prehospital emergency care is more likely to be delayed. Evidence is lacking on their contribution to rural healthcare provision, how care is provided and how this might be improved. We aimed to describe Community First Responder activities, organisation, costs of provision and outcomes of care together with perceptions and views of patients, public, Community First Responders, ambulance service staff and commissioners of their current and future role including innovations in the rural health and care workforce. Community First Responders are volunteers who attend emergencies, particularly in rural areas, and provide help until the ambulance arrives. Community First Responders (CFRs) are trained lay (and sometimes health professional) volunteers dispatched by Emergency Medical Services (EMS) to potentially life-threatening emergencies such as cardiac arrest in the first vital minutes to provide care until ambulance staff arrive. CFR schemes were first introduced to support ambulance services to rural communities where access to prehospital emergency care is more likely to be delayed. Apart from a few small-scale evaluations, surveys and qualitative studies of CFRs, evidence is lacking for their contribution to rural EMS provision, how care is provided and how this might be improved. We sought to provide evidence for the contribution and costs of CFR schemes to rural healthcare delivery and outcomes and to identify ways that these services can be improved, innovated or developed further to benefit rural communities. We aimed to investigate current activities, costs of provision and outcomes of CFR schemes, and explore views of patients, public, CFRs, CFR leads and primary care commissioners on CFRs, working with our stakeholders to develop recommendations for future innovations in rural CFR provision. Our objectives were to: 1. Describe the contribution of CFRs to rural healthcare provision in terms of the numbers and timing of calls attended, together with the types of conditions and characteristics of people attended. 2. Evaluate the costs, funding sources and consequences [response time, out-of-hospital cardiac arrest (OHCA) outcomes, response to falls] of CFR schemes. 3a. Explore ambulance policies, guidelines and protocols for CFRs. 3b. Explore stakeholder (patients, relatives, ambulance staff, primary care, commissioners, CFRs and CFR scheme organisers) experiences and perceptions of CFRs’ current role and the potential for future developments and innovations. We also aimed to ask CFRs and CFR scheme organisers about challenges in and solutions to recruiting, training and retaining CFRs in rural areas and how to ensure governance and accountability for safe, high-quality care. 4. Assimilate and integrate data derived from objectives 1–3, synthesising these to develop a list of recommendations for future innovations. 5. Prioritise recommendations for future developments/innovations in rural CFR provision through a consensus stakeholder workshop.

Authors' results and conclusions: In 4.5 million incidents from six English regional ambulance services during 2019, pre COVID-19 pandemic, Community First Responders attended first a higher proportion of calls in rural areas (almost 4% of calls) than in urban areas (around 1.5%). They were significantly more likely to be called out to rural (vs. urban) areas and to attend older (vs. younger), white (vs. minority ethnic) people in more affluent (vs. deprived) areas with cardiorespiratory and neurological (vs. other emergency) conditions for higher-priority emergency or urgent (category 1 and 2 compared with category 3, 4 or 5) calls but did also attend lower-category calls for conditions such as falls. We examined 10 documents from seven ambulance services. Ambulance policies and protocols integrated Community First Responders into ambulance service structures to achieve the safe and effective operation of volunteers. Costs, mainly for training, equipment and support, varied widely but were not always clearly delineated. Community First Responders enabled a faster prehospital response time. There was no clear benefit in out-of-hospital cardiac arrest outcomes. A specific Community First Responder falls response reduced ambulance attendances and was potentially cost saving. We conducted semistructured interviews with 47 different stakeholders engaged in Community First Responder functions. This showed the trajectory of becoming a Community First Responder, the Community First Responder role, governance and practice, and the positive views of Community First Responders from stakeholders despite public lack of understanding of their role. Community First Responders’ scope of practice varied between ambulance services and had developed into new areas. Innovations prioritised at the consensus workshop were changes in processes and structures and an expanded scope of practice supported by training, which included counselling, peer support, better communication with the control room, navigation and communication technology, and specific mandatory and standardised training for Community First Responders. Community First Responders have benefits in terms of response times and patient care. Future improvements should be evaluated. In 4.5 million incidents from six English regional ambulance services during 2019, pre 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). Community First Responders attended first in more than 9% of category 1 calls and almost 5% of category 2 calls. They first attended 6.5% of the total number of neurological (e.g. loss of consciousness, convulsions, collapse) or endocrine (e.g. hypo- or hyperglycaemia) conditions and 5.9% of the total number of cardiorespiratory conditions (including breathing problems, chest pain and stroke). In a multivariable model, the main predictors of CFR attendance were rurality [odds ratio (OR) 2.05, 95% confidence interval (CI) 1.99 to 2.11; p 

Authors' recommendations: Further research is needed to identify which innovations are taken up by CFR schemes and why, to evaluate the effectiveness and cost-effectiveness of CFR-related innovations, to explore the impact of the CFR role on individuals and communities, to understand how to motivate people to volunteer for CFR schemes, and how CFRs should be selected, trained and supported.

Authors' methods: We used a mixed-methods design, using a lens of pragmatism and the ‘actor’, ‘behaviour change’ and ‘causal pathway’ framework to integrate quantitative routine and qualitative (policy, guideline and protocol documents with stakeholder interview) data from 6 of 10 English ambulance services. We identified potential innovations in Community First Responder provision and prioritised these using a modified nominal group technique. Patients and public were involved throughout the study. Missing data and small numbers of interviews in some stakeholder groups (patients, commissioners) are sources of bias. We used a mixed-methods design, using a lens of pragmatism and the ‘actor’, ‘behaviour change’ and ‘causal pathway’ (ABC) framework to integrate quantitative (cross-sectional) and qualitative (policy, guideline and protocol document together with stakeholder interview) data using the ‘following the thread’ approach to triangulation. For the cross-sectional study of calls attended by CFRs, we used a retrospective observational study design, analysing routine electronic clinical records data from 6 of 10 regional ambulance services in England between 1 January 2019 and 31 December 2019. For the survey of CFR costs and resource use, we used a bespoke self-administered questionnaire e-mailed to ambulance trust directors of research and heads of research requesting information on the workforce of volunteer CFRs, the budget allocated to CFRs and the actual expenditure for the financial years 2017–8, 2018–9 and 2019–20. For the counterfactual analysis of the impact of CFR attendance on response times, we compared incidents that CFRs attended with those where ambulance staff attended in close geographical locations to derive response time distributions for each, adjusting by severity category and urban–rural classification, to estimate difference in attendance times and meeting of response target thresholds. For the analysis of OHCA outcomes related to CFR attendance, we derived Utstein-style templates for cardiac arrest incidents presenting to East Midlands Ambulance Service attended by both CFRs and ambulance staff. We compared outcomes for return of spontaneous circulation (ROSC) and 30-day survival using multivariable regressions models comparing CFR arrival before EMS with EMS alone for both. For the evaluation of the CFR response to falls provided by LIVES (Lincolnshire Integrated Voluntary Emergency Service), the falls response programme (FRP), introduced in Lincolnshire in 2019 and recommissioned after an initial pilot, we examined its operation, effects and cost-effectiveness during the period April 2020 to December 2021 using a cross-sectional design that linked falls episode data involving the programme from the ambulance service and the CFR scheme involved. We identified potential innovations in CFR provision that were prioritised using a modified nominal group technique in a consensus meeting. Patients and public were involved throughout the study.

Authors' identified further research: Future research should include a robust evaluation of innovations involving Community First Responders.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR127920

Year Published: 2024

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/JYRT8674

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/JYRT8674

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk