Community First Responders (CFRs) are trained members of the public, lay people or off-duty healthcare staff who volunteer to provide first aid. CFRs help ambulance services to provide care for people having health emergencies, from falls to road accidents to heart attacks, at home or in public places. CFRs are particularly important in rural areas where it is more difficult to provide or access emergency care, and where they are an important part of the care workforce. CFRs are broadly perceived to be positive, however evidence is needed about how they contribute to rural health services, which patients/conditions they attend, what care they provide, how effective they are and at what cost, how they are perceived by patients and other health workers, and how they could be developed to improve care for rural communities.

The investigators aim to develop recommendations for rural CFRs, by exploring their contribution to rural care, evaluating their value for money, understanding experiences and views of patients, CFRs and other healthcare staff, and exploring the potential for CFRs to provide new services.

The project will involve the following steps:

1. Analyse records from six ambulance services to see: how many people CFRs attended; the proportion of ambulance calls attended; age, sex and conditions of people attended; how quickly CFRs attended and what happened to the patient(s) when the ambulance arrived.
2. Evaluate benefits and costs of CFRs attending rural emergencies.
3. Interview patients/relatives, ambulance staff, GPs, funders, CFRs and CFR leads to obtain views on rural CFR current and potential future roles. Interviews will also explore with CFRs and CFR leads, challenges and solutions to recruiting, training, retaining rural CFRs and ensuring safe, high quality care.
4. Combine this knowledge (gained in steps1-3 above) to develop recommendations for change; who will be involved and how services should change to solve the most pressing problems for the rural communities served.
5. Present recommendations to a workshop of experts and public to agree priorities for future development.

Inclusion Criteria:

• Adults capable of giving informed consent. The investigators will 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 overseen schemes).

Exclusion Criteria:

• The investigators will exclude children and adults who are unable to give informed consent from this study.

London Ambulance Service NHS Trust is not included as it is mainly urban; East of England Ambulance Service and North East Ambulance Service are not included because of lack of electronic data.

For the interview studies the investigators will purposively sample patients, relatives, and ambulance staff identified from records of patients who have been attended by a CFR in a rural location in the previous six months. Where possible the investigators will interview patients, relatives, CFRs and ambulance staff attending the same event. GPs will be purposively sampled from rural areas of the ambulance services involved. The investigators will 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 overseen schemes).