FIGURE 1 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram
Nadine Dougall,*,† Stephen MacGillivray,‡ Inga Heyman,*,† Andrew Wooff,†,¶ Andrew Tatnell*,†
ABSTRACT
Effective cross-service collaboration has been posed as a way of improving outcomes for people, enhancing community safety and well-being, reducing social and health inequalities, and improving service resource efficiencies. However, it was not known what evidence and frameworks existed for service leads to reform collaborative public service responses.
This systematic review aimed to summarize evidence to understand best ways for police, fire, and ambulance services to collaborate to improve community safety and well-being. Standard methodology was used following PRISMA guidance. The search strategy optimized report retrieval from a broad range of academic databases, grey literature, and citation hand-searching from January 2012 to March 2022. Endnote 8 supported data management. Eligible reports explored collaboration benefits between any two emergency services to improve any aspect of community safety or well-being and had to provide relevant extractable information. Critical appraisal and syntheses of findings were conducted. Studies could originate from any country. Records were screened and retrieved by one author and included reports independently double-screened.
From the academic databases, 4,648 reports were identified and screened, of which 25 reports were retrieved and assessed for eligibility, but no relevant studies were retained following full text review. A further 27 records were identified from websites and citation searching, of which three were included following eligibility checks. The scant evidence uncovered in this review tentatively suggests service collaboration initiatives have potential for decreased resource use, increased public confidence, faster responses, increased survival rates, and reduced unnecessary emergency responses. Robust evidence is needed to influence policy and practice.
Key Words: Police, fire, and ambulance joint response, emergency response, inequality, resource use, partnership working, connected working
The benefits of cross-service collaboration have been posed as a means to improve outcomes for people, enhance community safety and well-being, reduce social and health inequalities, create better models of partnership working, and resource efficiencies for services (Christie Commission on the Future Delivery of Public Services, 2011; O’Neill & McCarthy, 2014; Rummery, 2009; Strudwick et al., 2022). In Scotland, the Christie Report acknowledged public service collaboration was central to achieving a fair society, being especially relevant in protecting those most vulnerable in society (Christie Commission on the Future Delivery of Public Services, 2011).
The Chiefs of Police Scotland, Scottish Fire & Rescue Service and Scottish Ambulance Service established the Reform Collaboration Group (RCG) to build collaboration aimed at improving outcomes for people in Scotland (Scottish Emergency Services National Collaboration Strategy, 2018). However, it was not known what UK or international evidence existed to inform the RCG collaborative project development strategies, whether individual outcomes were improved or intended benefits to services realized along with associated efficiencies. The RCG commissioned this review (Scottish Institute for Policing Research, 2021) to provide evidence to inform their project development work.
This review aimed to summarize relevant literature to understand best ways of police, fire, and ambulance services collaboration to improve community safety and well-being. The specific objectives were to establish what international evidence existed for effective collaboration between the three “Blue Light” emergency services for: community safety and well-being; reducing social and health inequities; primary, secondary, or tertiary prevention; best conditions for collaborative benefits including methodology and frameworks; cost-effective use of resources.
This systematic review was completed to PRISMA reporting guidelines (Page et al., 2021).
Studies were included if they: explored effectiveness/benefits including costs of cross-service collaboration (police, fire, ambulance) to provide improvements in community safety and well-being or reductions in social and health inequalities; provided sufficient information regarding aims, methods, focus, findings, and conclusions; published in English since January 2012.
Databases searched were: ASSIA; Sociological Abstracts; Social Services Abstracts; MEDLINE, PsycINFO, Social Care Online, Social Policy & Practice, Social Services Abstracts; Science Citation Index Expanded; Social Sciences Citation Index; Arts & Humanities Citation Index; Emerging Sources Citation Index; Conference Proceedings Citation Index Science; Conference Proceedings Citation Index Social Sciences & Humanities; Book Citation Index Science; Book Citation Index Social Sciences & Humanities; Campbell Collaboration. Past editions of the Journal of Emergency Management and International Journal of Emergency Services were hand-searched.
For the grey literature search, we performed extensive and iterative searches of Google and Google Scholar. We searched references and resources supplied by key national (including UK College of Policing) and international contacts regarding small-scale evaluations of change. We further augmented this via requests across our Twitter networks in March 2022. To check for Scottish relevance, we also searched websites of National Ambulance Research Steering Group (NARSG Ambulance Research); Fire Service Research and Training Trust via the portal Ignite (research – FSRTT (firetrust.info), and Scottish Institute for Policing Research (SIPR) including “select bibliography” of 2,945 records to March 2022.
Exploratory database searches were conducted for terms related to “Police or Fire or Ambulance” and combined with terms such as “Collaboration; Community safety; Wellbeing; Social inequalities; Health inequalities.” This exploratory pilot searching of the evidence did not identify relevant included studies but did refine our final search strategy with the following architecture:
The search architecture above contained dedicated terms used in advanced evidence base searches (e.g., “exp” means “explode” to capture all narrower terms associated with broader concepts). Reports had to be written in English as there was no budget for translation. There was no geographical limit on location of studies. Search results were downloaded into a reference management system (EndNote 8). Studies were retained if they met eligibility criteria. One author (SMacG) screened each record, retrieved included reports, and collected data from each report. Included reports were independently double-screened and confirmed (ND). No automation tools were used.
Data were extracted for: study design, methods, populations, intervention used, main concept, and outcomes for tri- and bi-partite service collaborations. Extracted data were cross-checked and disagreements resolved by consensus (all authors). We assessed included studies using the Assessment of Real-World Observational Studies (ArRoWS) critical appraisal tool (Coles et al., 2021) the Assessment of Real-World Observational Studies (ArRoWS). The ArRoWS tool contains nine identified core items to quickly and easily assess the quality of real-world evidence studies.
Characteristics of included reports were tabulated, with key information highlighted. All authors met to review tabulated data and identified key concepts to reach overarching narrative themes.
Following the final search strategy for trior bi-partite collaboration, 4,648 academic reports were identified and screened, of which 25 reports were retrieved and assessed for eligibility, leaving no new relevant studies after full text review (see Figure 1).
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FIGURE 1 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram | ||
Further iterative grey literature searching of many more thousands of potential documents and references resulted in 23 reports being retrieved, and, following eligibility assessment, three potential reports of interest were included (Bronsky et al., 2017; Elias et al., 2021; Emergency Services Collaboration Working Group, 2016). Contact with key experts and via Twitter elicited a small number of responses but did not yield any relevant reports. Given the apparent paucity of reports, care was taken to not exclude potentially relevant studies by retaining any with any relevance to community safety and well-being.
Excluded documents were tabulated, highlighting their focus and with comments on relevance, (see Supplemental Table S1). Table S1 demonstrates these documents were not research or evaluations of collaboration between any blue-light services focussed on improvements in community safety and well-being, or reductions in social and health inequalities. Many documents were news items, and very few related to community safety and well-being.
The three grey literature reports provided some relevant data and were from Australia, the United states, and the United Kingdom (see Table I). The first described a specific program to respond to the needs of vulnerable older people with an alternative to hospital admission (Elias et al., 2021). The second was a specific community program improving outcomes for people who frequently use Emergency Departments (EDs) (Bronsky et al., 2017). The third report was a “National Overview” of several projects and initiatives across England and Wales (Emergency Services Collaboration Working Group, 2016), which summarized activities by six main headings: “First response and co-responding,” “Demand management and rationalisation,” “Shared estates and assets,” “Joint control rooms,” “Wider collaboration,” and “Strategic alliances and partnerships”, reported in more detail in Table II.
TABLE I Summary of three included reports*
TABLE II Summary of the Emergency Services Collaboration Working Group 2016 report*
Two included studies were empirical real-world observational studies, one using a case study approach of data collected via quality improvement and service evaluation (Elias et al., 2021) and the other a retrospective program evaluation (Bronsky et al., 2017). We assessed these studies using the ArRoWS critical appraisal tool (Coles et al., 2021) the Assessment of Real-World Observational Studies (ArRoWS), finding some methodological issues, and Elias et al. offered more robust findings (see Table III).
TABLE III Critical appraisal using the ArRoWS tool
The first included report was by Elias et al. (2021), based in New South Wales, Australia, and described the development, implementation, and initial evaluation of the Geriatric Flying Squad’s reciprocal referral pathways with emergency responders including Ambulance, Police, and Fire and Rescue. The program avoided 331 estimated 9-1-1 calls per month, 144 ED visits per month, and 52 hospital admissions per month (see Table I).
The second included report was by Bronsky et al. (2017) based in Colorado, United States, and focussed on a subset of individuals who were “super-utilizers” of ED services. A community-wide collaboration program, Community Assistance Referral and Education Services (CARES), comprised several providers who interacted at different points during each patient’s intervention according to individual needs. Providers included fire fighters and paramedics. The study was a retrospective pre- and post-program evaluation, and the median (interquartile [IQR]) monthly rate of 9-1-1 calls, ED visits, and hospital admissions statistically significantly decreased by 0.26 (−0.06, 0.90), 0.25 (−0.08, 0.71), and 0.18 (0.04, 0.53), respectively, (p < 0.001 for all; see Table I).
The third and final included report was The Emergency Services Collaboration Working Group (2016), which provided examples of collaborative projects, plans, and initiatives from across England and Wales. There was some limited evidence regarding initiatives involving collaboration (see Table II):
The information retained from the grey literature was scant, and meaningful syntheses or assessments of evidence certainty were unfeasible.
Our review provided no peer reviewed empirical literature regarding collaboration between blue-light services with the specific intent to improve community safety and well-being. We could not provide any syntheses addressing the review objectives (i.e., there was no evidence in support of reducing social or health inequalities, or of methodologies or frameworks to deliver collaborative benefits, or cost-effective use of resources).
It was apparent from the grey literature retrieved that, in rare instances where blue-light services have formally collaborated and provided outcome data, the outcomes fell under one or more of the following: accessing services; emergency service usage and deployment (ambulances); ED usage and hospital admission; response times and survival rates; and public confidence. There were, in general, reported reductions in resource use and improved survival rates associated with increased efficiencies, and presumably reduced costs. This was accompanied by suggested improvements in public confidence in emergency services and increased community safety.
Although in the United Kingdom, the Policing and Crime Act 2017 (Policing and Crime Act 2017), the Crime and Disorder Act 1998 (Crime and Disorder Act 1998), and the policing principles of the Police and Fire Reform (Scotland) Act 2012 (Police and Fire Reform (Scotland) Act 2012) place a statutory duty on Police, Fire and Ambulance Services to consider collaboration to deliver efficiency, effectiveness, and/or better outcomes for communities, we found a distinct lack of evidence in support of these collaborations. However, it is possible that there are ongoing collaborations that have not reported findings, or are yet to report, and it may be worth updating this review in 5 years. One such initiative are the UK multi-agency safe-guarding hubs (MASH) intended to be effective multi-agency partnerships addressing the lack of information sharing between agencies, and preventing unnecessary exposure of people with vulnerability to harmful situations (Multi-agency working and information sharing-project: Final report, 2014). Evaluations of these initiatives did not appear in our search for evidence, and it is likely that the multi-agency approach includes blue-light services but not with bi- or tri-partite related outcomes—one notable example did mention fire and police included as multi-agencies. However, the outcomes were not bi-partite and did not meet our inclusion criteria (Shorrock et al., 2020).
Alongside this review, SIPR also funded a case study evaluation of cross-service collaboration using a community hub model, providing further evidence of cross-service collaboration (Dougall et al., 2023). The SIPR-funded case study was commissioned by the RCG in Scotland and illustrates the progressive approach in recognizing the value of evidence for collaborative partnership working and leadership (Docherty & Russell, 2022).
A previous review of research into emergency services collaboration by Parry and colleagues in 2015 noted that “most of the academic literature tends to focus on major incidents, small case studies or responding to major incidents” (Parry et al., 2015, p. 4). Our review found a substantial evidence gap of peer reviewed empirical literature regarding collaboration between blue-light services designed to improve community safety and well-being. Very little evidence appears to have been reported (or be available) regarding evaluations of collaborative initiatives in this area.
Our search terms aimed to find evidence for blue-light collaboration to improve community safety and well-being or reduce inequalities. The search terms were not designed to capture emergency and disaster responses, where it is likely that much more literature is available for collaborative blue-light responses, and it is possible that community prevention activities were not the focus but included as secondary outcomes and missed in this review. It is also possible that the broader emergency management literature beyond blue-light response to other agencies also contained relevant evidence and should be considered in future research. Another possible limitation is that blue-light services may be in possession of consultancy reports for internal use only, embargoed for a variety of reasons and unavailable to researchers to identify. However, we did ask our steering group blue-light service representatives to identify and produce any relevant such reports, and none were forthcoming because they did not exist. Relevant items may also have been missed due to inconsistent terminology between reports, contributing to the sparse documentation retrieved, the language limited to English only due to budget constraints, and being published prior to January 2012. Finally, we did not register the review protocol in advance of the review, and this would have improved the rigour by pre-specifying our stated aims.
Future literature reviews should focus on broader collaboration work involving other agencies beyond blue-light services (e.g., multi-agency safeguarding hub (MASH) initiatives) (Shorrock et al., 2020) or specific topic examples that may inform future collaboration (e.g., police carriage of naloxone) (Speakman et al., 2023). There is a real need for blue-light service collaborations to go beyond internal reviews of effectiveness of collaborations and, where possible, document and publish outcomes stemming from these collaborations to provide high-quality evidence of potentially effective collaboration. Ideally these collaborations should be independently evaluated and published in academic journals to inform future evidence-based initiatives.
To our knowledge, this is the first review to summarize blue-light service collaborations to improve community safety and well-being. Although this review only retrieved three reports, the scant evidence uncovered suggests that service collaboration initiatives have potential for decreased resource use across services, increased public confidence, faster responses, increased survival rates, and reduced risks associated with unnecessary emergency responses from other services. In future, blue-light services should consider these preliminary findings and focus more on problem-solving initiatives for improving communities’ safety and well-being to ascertain whether any of these associated public health and service benefits are realized. In order to demonstrate impact and inform evidence-based approaches to blue-light collaboration, it is imperative that such collaborative work be independently evaluated to provide robust evidence of what works to influence policy and practice nationally and internationally.
We extend thanks to the project Steering Group for their oversight: Clair Thomson (Police Scotland), Mark McAteer (Scottish Fire & Rescue Services), Julie Carter (Scottish Ambulance Service) and their designated deputies. We acknowledge SIPR for funding the study and thank Dr. Kristy Docherty for comments regarding collaborative leadership between police and other agencies in Scotland.
The authors declare that there are no conflicts of interest.
*School of Health & Social Care, Edinburgh Napier University, Edinburgh, Scotland;
†Scottish Centre for Policing & Public Health, Edinburgh Napier University, Edinburgh, Scotland;
‡Sirius Systematic Review Services Ltd, Gardenstown, Scotland;
¶School of Applied Sciences, Edinburgh Napier University, Edinburgh, Scotland.
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Supplemental material for this article available online at journalcswb.ca/index.php/cswb/article/view/319/supp_material
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Journal of CSWB, VOLUME 8, NUMBER 2, June 2023