"It's like a swan, all nice and serene on top, and paddling like hell underneath": community first responders' practices in attending patients and contributions to rapid emergency response in rural England, United Kingdom-a qualitative interview study.

BACKGROUND: Community First Responder (CFR) schemes are a long-established service supplementing ambulance trusts in their local community in the United Kingdom. CFRs are community members who volunteer to respond to people with life-threatening conditions. Previous studies highlighted the motivations for becoming CFRs, their training, community (un)awareness and implications of their work on themselves and others. The practices of CFRs in prehospital care remain underexplored. Therefore, we aimed to explore real-world practice of Community First Responders and their contribution to prehospital emergency care. METHODS: We conducted 47 interviews with CFRs (21), CFR leads (15), ambulance clinicians (4), commissioners (2) and patients and relatives (5) from six ambulance services and regions of England, United Kingdom. Thematic analysis enabled identification of themes and subthemes, with subsequent interpretation built on the theory of practice wisdom. RESULTS: Our analysis revealed the embeddedness of the concept of doing the right thing at the right time in CFR practice. CFRs' work consisted of a series of sequential and interconnected activities which included: identifying patients' signs, symptoms and problems; information sharing with the ambulance control room on the patient's condition; providing a rapid emergency response including assessment and care; and engaging with ambulance clinicians for patient transfer. The patient care sequence began with recognising patients' signs and symptoms, and validation of patient information provided by the ambulance control room. The CFRs shared patient information with ambulance control who in turn notified the ambulance crew en-route. The practices of CFRs also included delivery of emergency care before ambulance clinicians arrived. Following the delivery of a rapid emergency response, CFRs engaged with the ambulance crew to facilitate patient transfer to the nearest medical facility. CONCLUSION: The sequential CFR practices supported ambulance services in delivering prehospital and emergency care in rural areas. CFR practices were founded on the principle of practice wisdom where CFRs constructed their practice decisions based on the patient's condition, their training, availability of equipment and medications and their scope of practice.

Common hierarchies, varied rules - the problem of governing community first responders in prehospital care for quality standards: documentary discourse analysis.

A key focus is placed on engaging communities to become involved in making decisions to support health and care services in healthcare policies in England, UK. An example is the deployment of volunteers such as community first responders (CFRs), who are members of the public with basic life support skills, trained to intervene in emergency situations prior to the arrival of ambulance services. CFR policies have been devised by National Health Service (NHS) Trusts as a way of governing these and related activities. This paper critically examines the discourse around CFR policies to understand how CFR roles are organised and monitoring governance mechanisms are delineated in ensuring quality care delivery. We collected ten CFR policies from six ambulance services. Inductive analysis, guided by Foucault's theory, enabled the identification of themes and subthemes. We found that Trusts have a common goal to make care quality assurances to regulatory bodies on CFR roles, and this is depicted in common hierarchies of individual responsibilities across Trusts. However, policies that govern approaches to CFRs activity vary. Firstly, the paper highlights institutional approaches to ensuring public safety through the application of organised surveillance systems to monitor CFR activities, and draws parallels between such surveillance and Foucault's docile bodies. Secondly, the paper discusses how varying rules in the surveillance system compromises safety by decentralising knowledge to regulatory bodies to whom NHS Trusts must make safety assurances. We suggest that stronger interrelationships between Trusts in considering the CFR role has potential to increase public safety and outline a clearer direction for CFRs.

Examiner perceptions of the MRCGP recorded consultation assessment for general practice licensing during COVID-19: cross-sectional study.

BACKGROUND: The Recorded Consultation Assessment (RCA) was developed rapidly during the COVID-19 pandemic to replace the Clinical Skills Assessment (CSA) for UK general practice licensing. Our aim was to evaluate examiner perceptions of the RCA. METHODS: We employed a cross-sectional design using a questionnaire survey of RCA examiners with attitudinal (relating to examiners thoughts and perceptions of the RCA) and free text response options. We conducted statistical descriptive and factor analysis of quantitative data with qualitative thematic analysis of free text responses. RESULTS: Overall, 182 of 260 (70%) examiners completed the questionnaire. Responders felt that consultations submitted were representative of the work of a typical GP during the pandemic and provided a good sample across the curriculum. They were also generally positive about the logistic, advisory and other support provided as well as the digital platform. Despite responders generally agreeing there was sufficient information available in video or audio consultations to judge candidates' data gathering, clinical management, and interpersonal skills, they were less confident about their ability to make judgments of candidates' performance compared with the CSA. The qualitative analysis of free text responses detailed the problems of case selection and content, explained examiners' difficulties when making judgments, and detailed the generally positive views about support, training and information technology. Responders also provided helpful recommendations for improving the assessment. CONCLUSION: The RCA was considered by examiners to be feasible and broadly acceptable, although they experienced challenges from candidate case selection, case content and judgments leading to suggested areas for improvement.

Community First Responders' Contribution to Emergency Medical Service Provision in the United Kingdom.

STUDY OBJECTIVE: We aimed to investigate community first responders' contribution to emergency care provision in terms of number, rate, type, and location of calls and characteristics of patients attended. METHODS: We used a retrospective observational design analyzing routine data from electronic clinical records from 6 of 10 ambulance services in the United Kingdom during 2019. Descriptive statistics, including numbers and frequencies, were used to illustrate characteristics of incidents and patients that the community first responders attended first in both rural and urban areas. RESULTS: The data included 4.5 million incidents during 1 year. The community first responders first attended a higher proportion of calls in rural areas compared with those in urban areas (3.90% versus 1.48 %). In rural areas, the community first responders also first attended a higher percentage of the most urgent call categories, 1 and 2. The community first responders first attended more than 9% of the total number of category 1 calls and almost 5% of category 2 calls. The community first responders also attended a higher percentage of the total number of cardiorespiratory and neurological/endocrine conditions. They first attended 6.5% of the total number of neurological/endocrine conditions and 5.9% of the total number of cardiorespiratory conditions. Regarding arrival times in rural areas, the community first responders attended higher percentages (more than 6%) of the total number of calls that had arrival times of less than 7 minutes or more than 60 minutes. CONCLUSION: In the United Kingdom, community first responders contribute to the delivery of emergency medical services, particularly in rural areas and especially for more urgent calls. The work of community first responders has expanded from their original purpose-to attend to out-of-hospital cardiac arrests. The future development of community first responders' schemes should prioritize training for a range of conditions, and further research is needed to explore the contribution and potential future role of the community first responders from the perspective of service users, community first responders' schemes, ambulance services, and commissioners.

The experiences and perceptions of wellbeing provision among English ambulance services staff: a multi-method qualitative study.

BACKGROUND: NHS ambulance service staff are at risk of poor physical and mental wellbeing because of the likelihood of encountering stressful and traumatic incidents. While reducing sickness absence and improving wellbeing support to ambulance staff is a key NHS priority, few studies have empirically documented a national picture to inform policy and service re-design. The study aimed to understand how ambulance service trusts in England deal with staff health and wellbeing, as well as how the staff perceive and use wellbeing services. METHODS: To achieve our aim, we undertook semi-structured telephone interviews with health and wellbeing leads and patient-facing ambulance staff, as well as undertaking documentary analysis of ambulance trust policies on wellbeing. The study was conducted both before and during the UK first COVID-19 pandemic wave. The University of Lincoln ethics committee and the Health Research Authority (HRA) granted ethical approval. Overall, we analysed 57 staff wellbeing policy documents across all Trusts. Additionally, we interviewed a Health and Wellbeing Lead in eight Trusts as well as 25 ambulance and control room staff across three Trusts. RESULTS: The study highlighted clear variations between organisational and individual actions to support wellbeing across Trust policies. Wellbeing leads acknowledged real 'tensions' between individual and organisational responsibility for wellbeing. Behaviour changes around diet and exercise were perceived to have a positive effect on the overall mental health of their workforce. Wellbeing leads generally agreed that mental health was given primacy over other wellbeing initiatives. Variable experiences of health and wellbeing support were partly contingent on the levels of management support, impacted by organisational culture and service delivery challenges for staff. CONCLUSION: Ambulance service work can impact upon physical and mental health, which necessitates effective support for staff mental health and wellbeing. Increasing the knowledge of line managers around the availability of services could improve engagement.

The prehospital care experiences and perceptions of ambulance staff and Eastern European patients: An interview study in Lincolnshire, UK.

Background: EU enlargement after 2004 was a major factor in increasing Eastern European migration to the UK. This population requires access to high quality public services generally, and ambulance services more specifically. To understand how Eastern European migrants use ambulance care, this study explored the perceptions and experiences of ambulance staff and the Eastern European patients themselves. Methods: We undertook qualitative semi-structured interviews across Lincolnshire. Purposive and maximum variation sampling ensured that participants were knowledgeable about Eastern European patients' use of ambulance care and were demographically diverse. Data were analysed using framework analysis. Results: There were interviews with 15 ambulance staff and 12 Eastern European patients. A staff interviewee problematised "Health Tourism", which suggests that migrants deliberately exploit state-funded healthcare. However, most disagreed. Patient interviewees often undertook medical travel to access healthcare in response to perceived healthcare problems in the UK. Medical travel increased the likelihood of ambulance staff encountering foreign medication. Variable quality of, and access to, professional interpreters prompted patients to rely instead on informal interpreters. Patients did not register with GPs perhaps due to limited understanding of how the NHS worked. This led to inappropriate use of ambulance services. Recommendations for service delivery improvements included: Eastern European language information on how and when to use ambulance care; improving GP registration; and greater engagement between the ambulance service and Eastern European communities. Conclusions: Frequent medical travel can limit how Eastern Europeans acculturate to the NHS and anchor roots in the UK. Acculturation is about how migrant cultures adjust to the host country. This is not assimilation, where they dilute their cultural identity. Language and communication barriers, as well as inadequate availability and quality of interpreting services, can impede patient-staff dialogue in time-critical emergencies.

Candidate perceptions of the UK Recorded Consultation Assessment: cross-sectional data linkage study.

The Recorded Consultation Assessment (RCA) was rapidly developed to replace the Clinical Skills Assessment (CSA) for UK general practice licencing during COVID-19. We aimed to evaluate candidate perceptions of the RCA and relationships with performance. We conducted a cross-sectional survey of RCA candidates with attitudinal, demographic, and free text response options, undertaking descriptive and factor analysis of quantitative data with qualitative thematic analysis of free text. Binomial regression was used to estimate associations between RCA pass, candidate characteristics and questionnaire responses.645 of 1551 (41.6%) candidates completed a questionnaire; 364 (56.4%) responders permitted linkage with performance and demographic data. Responders and non-responders were similar in exam performance, gender and declared disability but were significantly more likely to be UK graduates (UKG) or white compared with international medical (IMG) or ethnic minority graduates. Responders were positive about the digital platform and support resources. A small overall majority regarded the RCA as a fair assessment; a larger majority reported difficulty collecting, selecting, and submitting cases or felt rushed during recording.Logistic regression showed that ethnicity (white vs minority ethnic: odds ratio [OR] 2.99,95% confidence interval [CI] 1.23, 7.30, p = 0.016), training (UK vs IMG: OR 6.88, 95% CI 2.79, 16.95, p < 0.001), and English as first language (OR 5.11, 0% CI 2.08, 12.56, p < 0.001) were associated with exam success but questionnaire subscales, consultation type submitted, or extent of trainer review were not. The RCA was broadly acceptable but experiences were variable. Candidates experienced challenges and suggested areas for improvement.

Trends, variations and prediction of staff sickness absence rates among NHS ambulance services in England: a time series study.

OBJECTIVES: Our aim was to measure ambulance sickness absence rates over time, comparing ambulance services and investigate the predictability of rates for future forecasting. SETTING: All English ambulance services, UK. DESIGN: We used a time series design analysing published monthly National Health Service staff sickness rates by gender, age, job role and region, comparing the 10 regional ambulance services in England between 2009 and 2018. Autoregressive Integrated Moving Average (ARIMA) and Seasonal ARIMA (SARIMA) models were developed using Stata V.14.2 and trends displayed graphically. PARTICIPANTS: Individual participant data were not available. The total number of full-time equivalent (FTE) days lost due to sickness absence (including non-working days) and total number of days available for work for each staff group and level were available. In line with The Data Protection Act, if the organisation had less than 330 FTE days available during the study period it was censored for analysis. RESULTS: A total of 1117 months of sickness absence rate data for all English ambulance services were included in the analysis. We found considerable variation in annual sickness absence rates between ambulance services and over the 10-year duration of the study in England. Across all the ambulance services the median days available were 1 336 888 with IQR of 548 796 and 73 346 median days lost due to sickness absence, with IQR of 30 551 days. Among clinical staff sickness absence varied seasonally with peaks in winter and falls over summer. The winter increases in sickness absence were largely predictable using seasonally adjusted (SARIMA) time series models. CONCLUSION: Sickness rates for clinical staff were found to vary considerably over time and by ambulance trust. Statistical models had sufficient predictive capability to help forecast sickness absence, enabling services to plan human resources more effectively at times of increased demand.

Understanding how Eastern European migrants use and experience UK health services: a systematic scoping review.

BACKGROUND: The UK has experienced significant immigration from Eastern Europe following European Union (EU) expansion in 2004, which raises the importance of equity and equality for the recent immigrants. Previous research on ethnic health inequalities focused on established minority ethnic groups, whereas Eastern European migrants are a growing, but relatively under-researched group. We aimed to conduct a systematic scoping review of published literature on Eastern European migrants' use and experiences of UK health services. METHODS: An initial search of nine databases produced 5997 relevant publications. Removing duplicates reduced the figure to 2198. Title and abstract screening left 73 publications. Full-text screening narrowed this down further to 10 articles, with three more from these publications to leave 13 included publications. We assessed publications for quality, extracted data and undertook a narrative synthesis. RESULTS: The included publications most commonly studied sexual health and family planning services. For Eastern European migrants in the UK, the most commonly cited barriers to accessing and using healthcare were limited understanding of how the system worked and language difficulties. It was also common for migrants to return to their home country to a healthcare system they were familiar with, free from language barriers. Familial and social networks were valuable for patients with a limited command of English in the absence of suitable and available interpreting and translating services. CONCLUSIONS: To address limited understanding of the healthcare system and the English language, the NHS could produce information in all the Eastern European languages about how it operates. Adding nationality to the Electronic Patient Report Form (EPRF) may reveal the demand for interpretation and translation services. Eastern European migrants need to be encouraged to register with GPs to reduce A&E attendance for primary care conditions. Many of the issues raised will be relevant to other European countries since the long-term outcomes from Brexit are likely to influence the level of Eastern European and non-Eastern European migration across the continent, not just the UK.

Patient and clinician factors associated with prehospital pain treatment and outcomes: cross sectional study.

OBJECTIVE: We aimed to identify how patient (age, sex, condition) and paramedic factors (sex, role) affected prehospital analgesic administration and pain alleviation. METHODS: We used a cross-sectional design with a 7-day retrospective sample of adults aged 18 years or over requiring primary emergency transport to hospital, excluding patients with Glasgow Coma Scale below 13, in two UK ambulance services. Multivariate multilevel regression using Stata 14 analysed factors independently associated with analgesic administration and a clinically meaningful reduction in pain (≥2 points on 0-10 numerical verbal pain score [NVPS]). RESULTS: We included data on 9574 patients. At least two pain scores were recorded in 4773 (49.9%) patients. For all models fitted there was no significant relationship between analgesic administration or pain reduction and sex of the patient or ambulance staff. Reduction in pain (NVPS ≥2) was associated with ambulance crews including at least one paramedic (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14 to 2.04, p < 0.01), with any recorded pain score and suspected cardiac pain (OR 2.2, 95% CI 1.02 to 4.75). Intravenous morphine administration was also more likely where crews included a paramedic (OR 2.82, 95% CI 1.93 to 4.13, P < 0.01), attending patients aged 51 to 64 years (OR 2.04, 95% CI 1.21 to 3.45, p = 0.01), in moderate to severe (NVPS 4-10) compared with lower levels of pain for any clinical condition group compared with the reference condition. CONCLUSION: There was no association between patient sex or ambulance staff sex or grade and analgesic administration or pain reduction.

Factors that motivate individuals to volunteer to be dispatched as first responders in the event of a medical emergency: A systematic review protocol.

Background: Voluntary First Response is an important component of prehospital care for medical emergencies, particularly cardiac arrest, in many countries. This intervention entails the mobilisation of volunteers, known as Community First Responders (CFRs), by the Emergency Medical Services to respond to medical emergencies in their locality. They include lay responders and/or professional responders (e.g. police officers, fire fighters, and general practitioners). A wide variety of factors are thought to motivate CFRs to join and remain engaged in Voluntary First Response schemes, such as the availability of learning opportunities, recognition, counselling, and leadership. The aim of this review is to develop an in-depth understanding of CFR motivation, including the factors that influence the initial decision to volunteer as a CFR and the factors that sustain involvement in Voluntary First Response over time. Any factors relevant to CFR de-motivation and turnover will also be examined. Methods: This is a protocol for a qualitative systematic review of the factors that influence the motivation of individuals to participate in Voluntary First Response. A systematic search will be carried out on seven electronic databases. Qualitative studies, mixed-methods studies, and any other studies producing data relating to the review question will be eligible for inclusion. Title and abstract screening, as well as full text screening, will be completed independently by two authors. A narrative synthesis, which is an established qualitative synthesis methodology, will be performed. The quality of each of the included studies will be critically appraised. Discussion: The findings of this review will be used to optimise the intervention of Voluntary First Response. Specifically, the results will inform the design and organisation of Voluntary First Response schemes, including their recruitment, training, and psychological support processes. This could benefit a range of stakeholders, including CFRs, paramedics, emergency physicians, patients, and the public.

Perceptions and experiences of community first responders on their role and relationships: qualitative interview study.

BACKGROUND: Community First Responders (CFRs) are lay volunteers who respond to medical emergencies. We aimed to explore perceptions and experiences of CFRs in one scheme about their role. METHODS: We conducted semi-structured interviews with a purposive sample of CFRs during June and July 2016 in a predominantly rural UK county. Interviews were transcribed verbatim and analysed using the Framework method, supported by NVivo 10. RESULTS: We interviewed four female and 12 male adult CFRs aged 18-65+ years with different levels of expertise and tenures. Five main themes were identified: motivation and ongoing commitment; learning to be a CFR; the reality of being a CFR; relationships with statutory ambulance services and the public; and the way forward for CFRs and the scheme. Participants became CFRs mainly for altruistic reasons, to help others and put something back into their community, which contributed to personal satisfaction and helped maintain their involvement over time. CFRs valued scenario-based training and while some were keen to access additional training to enable them to attend a greater variety of incidents, others stressed the importance of maintaining existing abilities and improving their communication skills. They were often first on scene, which they recognised could take an emotional toll but for which they found informal support mechanisms helpful. Participants felt a lack of public recognition and sometimes were undervalued by ambulance staff, which they thought arose from a lack of clarity over their purpose and responsibilities. Although CFRs perceived their role to be changing, some were fearful of extending the scope of their responsibilities. They welcomed support for volunteers, greater publicity and help with fundraising to enable schemes to remain charities, while complementing the role of ambulance services. DISCUSSION: CFR schemes should consider the varying training, development and support needs of staff. CFRs wanted schemes to be complementary but distinct from ambulance services. Further information on outcomes and costs of the CFR contribution to prehospital care is needed. CONCLUSION: Our findings provide insight into the experiences of CFRs, which can inform how the role might be better supported. Because CFR schemes are voluntary and serve defined localities, decisions about levels of training, priority areas and targets should be locally driven. Further research is required on the effectiveness, outcomes, and costs of CFR schemes and a wider understanding of stakeholder perceptions of CFR and CFR schemes is also needed.

Prioritizing novel and existing ambulance performance measures through expert and lay consensus: A three-stage multimethod consensus study.

BACKGROUND: Current ambulance quality and performance measures, such as response times, do not reflect the wider scope of care that services now provide. Using a three-stage consensus process, we aimed to identify new ways of measuring ambulance service quality and performance that represent service provider and public perspectives. DESIGN: A multistakeholder consensus event, modified Delphi study, and patient and public consensus workshop. SETTING AND PARTICIPANTS: Representatives from ambulance services, patient and public involvement (PPI) groups, emergency care clinical academics, commissioners and policymakers. RESULTS: Nine measures/principles were highly prioritized by >75% of consensus event participants, including measures relating to pain, patient experience, accuracy of dispatch decisions and patient safety. Twenty experts participated in two Delphi rounds to further refine and prioritize measures; 20 measures in three domains scored ≥8/9, indicating good consensus, including proportion of calls correctly prioritized, time to definitive care and measures related to pain. Eighteen patient/public representatives attended a consensus workshop, and six measures were identified as important. These include time to definitive care, response time, reduction in pain scores, calls correctly prioritized to appropriate levels of response and survival to hospital discharge for treatable emergency conditions. CONCLUSIONS: Using consensus methods, we identified a shortlist of ambulance outcome and performance measures that are important to ambulance clinicians and service providers, service users, commissioners, and clinical academics, reflecting current pre-hospital ambulance care and services. The measures can potentially be used to assess pre-hospital quality or performance over time, with most calculated using routinely available data.

Community first responders and responder schemes in the United Kingdom: systematic scoping review.

BACKGROUND: Community First Responder (CFR) schemes support lay people to respond to medical emergencies, working closely with ambulance services. They operate widely in the UK. There has been no previous review of UK literature on these schemes. This is the first systematic scoping review of UK literature on CFR schemes, which identifies the reasons for becoming a CFR, requirements for training and feedback and confusion between the CFR role and that of ambulance service staff. This study also reveals gaps in the evidence base for CFR schemes. METHODS: We conducted a systematic scoping review of the published literature, in the English language from 2000 onwards using specific search terms in six databases. Narrative synthesis was used to analyse article content. RESULTS: Nine articles remained from the initial search of 15,969 articles after removing duplicates, title and abstract and then full text review. People were motivated to become CFRs through an altruistic desire to help others. They generally felt rewarded by their work but recognised that the help they provided was limited by their training compared with ambulance staff. There were concerns about the possible emotional impact on CFRs responding to incidents. CFRs felt that better feedback would enhance their learning. Ongoing training and support were viewed as essential to enable CFRs to progress. They perceived that public recognition of the CFR role was low, patients sometimes confusing them with ambulance staff. Relationships with the ambulance service were sometimes ambivalent due to confusion over roles. There was support for local autonomy of CFR schemes but with greater sharing of best practice. DISCUSSION: Most studies dated from 2005 and were descriptive rather than analytical. In the UK and Australia CFRs are usually lay volunteers equipped with basic skills for responding to medical emergencies, whereas in the US they include other emergency staff as well as lay people. CONCLUSION: Opportunities for future research include exploring experiences and perceptions of patients who have been treated by CFRs and other stakeholders, while also evaluating the effectiveness and costs of CFR schemes.

Ethnicity and pre-hospital care for people with suspected cardiac pain: cross-sectional study.

OBJECTIVES: Few studies have investigated the quality of pre-hospital care by ethnicity. We aimed to investigate ethnic differences in pre-hospital ambulance care of patients with suspected cardiac pain. METHODS: We conducted a cross-sectional analysis of retrospective electronic clinical data for patients with suspected cardiac pain over one year (August 2011 to July 2012) extracted from a single regional ambulance service. This included patient demographic data, clinical measurements, drugs administered and outcomes, such as transportation to hospital or referral to primary care. We used multivariate regression to investigate differences in care by ethnicity comparing non-White with White patients. RESULTS: There were 7046 patients with suspected cardiac pain, with 4825 who had ethnicity recorded including 4661 (96.6%) White and 164 (3.4%) non-White. After correcting for age, sex, socio-economic status and whether transported to hospital, non-White patients were significantly more likely to have temperature [odds ratio (OR) 2.96, P = 0.007], blood glucose (OR 3.95, P = 0.003), respiratory rate (OR 4.94, P = 0.03) and oxygen saturation (OR 2.43, P = 0.006) recorded. Non-White patients were significantly less likely to be transported to hospital (OR 0.43, P = 0.03). CONCLUSION: There were significant differences in pre-hospital ambulance care for non-White compared with White patients with suspected cardiac pain. These differences could be due to differences in clinical condition or case-mix, language and cultural barriers, limited understanding of appropriate use of health care services, recording bias or true differences in provider management. Further analysis should involve larger and more complete data sets to explore ethnic differences in greater detail.

Exploration of contextual factors in a successful quality improvement collaborative in English ambulance services: cross-sectional survey.

RATIONALE, AIMS AND OBJECTIVES: Clinical leadership and organizational culture are important contextual factors for quality improvement (QI) but the relationship between these and with organizational change is complex and poorly understood. We aimed to explore the relationship between clinical leadership, culture of innovation and clinical engagement in QI within a national ambulance QI Collaborative (QIC). METHODS: We used a self-administered online questionnaire survey sent to front-line clinicians in all 12 English ambulance services. We conducted a cross-sectional analysis of quantitative data and qualitative analysis of free-text responses. RESULTS: There were 2743 (12% of 22 117) responses from 11 of the 12 participating ambulance services. In the 3% of responders that were directly involved with the QIC, leadership behaviour was significantly higher than for those not directly involved. QIC involvement made no significant difference to responders' perceptions of the culture of innovation in their organization, which was generally considered poor. Although uptake of QI methods was low overall, QIC members were significantly more likely to use QI methods, which were also significantly associated with leadership behaviour. CONCLUSIONS: Despite a limited organizational culture of innovation, clinical leadership and use of QI methods in ambulance services generally, the QIC achieved its aims to significantly improve pre-hospital care for acute myocardial infarction and stroke. We postulate that this was mediated through an improvement subculture, linked to the QIC, which facilitated large-scale improvement by stimulating leadership and QI methods. Further research is needed to understand success factors for QI in complex health care environments.

Reassurance as a key outcome valued by emergency ambulance service users: a qualitative interview study.

BACKGROUND: There is an increasing need to assess the performance of emergency ambulance services using measures other than the time taken for an ambulance to arrive on scene. In line with government policy, patients and carers can help to shape new measures of ambulance service performance. OBJECTIVE: To investigate the aspects of emergency ambulance service care valued by users. DESIGN: Qualitative interview study. SETTING: One of 11 ambulance services in England. PARTICIPANTS: Twenty-two users and eight of their spouses (n = 30). RESULTS: Users of the emergency ambulance service, experiencing different types of ambulance service response, valued similar aspects of their pre-hospital care. Users were often extremely anxious about their health, and the outcome they valued was reassurance provided by ambulance service staff that they were receiving appropriate advice, treatment and care. This sense of being reassured was enhanced by the professional behaviour of staff, which instilled confidence in their care; communication; a short wait for help; and continuity during transfers. A timely response was valued in terms of allaying anxiety quickly. DISCUSSION AND CONCLUSIONS: The ability of the emergency ambulance service to allay the high levels of fear and anxiety felt by users is crucial to the delivery of a high quality service. Measures developed to assess and monitor the performance of emergency ambulance services should include the proportion of users reporting feeling reassured by the response they obtained.