For many who work in the NHS, and indeed for the vast majority of those who use it, the term “failure demand” might seem quite alien, but the concepts it sets out are all too familiar.
At National Voices, we hear about the symptoms of failure demand constantly. People chasing referrals that have gone missing. Having to repeat their story to multiple professionals because systems don’t speak to each other. Turning up to appointments unsure why they are there, or worse, getting a letter informing them about an appointment after the date it was due to take place – something experienced by a staggering 1 in 4 NHS patients last year!
The waste is screamingly obvious to the public, with our own research showing that it is denting confidence in the NHS’s ability to use its resources wisely and has created, at times, a system so hard to engage with that people give up. This is bad for patients, and the system, as it simply stores up problems that will be more costly to resolve and the outcomes likely less good.
Fancy names
It’s therefore slightly galling that we have to give a fancy name to this problem to get NHS leaders to pay attention. But I have been around long enough to recognise that the health service, as a large and complex bureaucracy, needs to approach problems in this way to get its massive corporate head around the challenge.
The NHS needs frameworks, typologies, and language that translates messy human experience into something legible for policy, performance and planning. And that’s what this new report from the Strategy Unit does. It connects those everyday frustrations to the productivity challenge facing the NHS. It makes explicit something that is often left unsaid: that a significant proportion of activity may be generated not by new need, but by the system failing to meet existing need the first time.
But if we are not careful, we risk stopping at recognition — and missing the harder implications.
What we choose to measure
The report is right to warn against turning failure demand into a KPI. That path, whilst tempting for politicians and policy makers looking to drive rapid improvements in efficiency, leads quickly to gaming and perverse incentives.
Neither can we continue to prioritise activity and finance metrics that systematically overlook the problem. One of the report’s strongest insights is that the costs of failure demand are often borne by patients and carers, in terms of time, effort, stress and lost income.
The logical move then, is to make patient experience measures much more important. After all, it is the only real way that systems will be able to see where failure demand exists and understand how to address it.
The importance of evidence
Failure demand is, by its nature, difficult to quantify. It relies on judgement: whether a contact was necessary, whether a need could have been met earlier, whether the system got it right first time. The report leans into this ambiguity, arguing that the concept is best used as a diagnostic lens rather than a measurement tool.
That is sensible. But it should also give leaders permission to act without perfect data.
In many cases, the causes of failure demand are not subtle. They are structural, visible and long-standing. If a service routinely fails to provide BSL interpreters because it does not record whether patients are D/deaf, the problem is not one of measurement. It is one of design. Waiting to quantify the scale of the issue risks entrenching it.
Too often, the NHS defaults to asking “how big is the problem?” before asking “is this acceptable?” The concept of failure demand should prompt a reversal of that instinct.
What to stop
The goal of understanding failure demand, is not to do more with less but to do less of the wrong things. In practice, this is where the NHS has struggled.
Decisions about what constitutes “low value” are rarely neutral. They are shaped by clinical priorities, financial pressures and institutional incentives — and they do not always align with what matters to patients. Attempts to restrict provision in areas such as fertility treatment have often been framed in terms of value, yet can generate significant downstream demand elsewhere in the system.
As the report notes, failure demand does not stay neatly within organisational boundaries. It amplifies, shifts and reappears, often in more complex and costly forms. So any serious attempt to “stop doing” must take a whole-system view of value, not just a narrow assessment of individual services.
The importance of language
The report suggests that “failure demand” may be too blunt a term, particularly for frontline staff who may feel blamed for problems they did not create. There is truth in this. Language matters, and poorly chosen words can close down engagement.
But there is also a risk in softening it too much.
“Getting it right first time” is easier to accept, but it is also easier to ignore. “Failure demand”, by contrast, is uncomfortable. It draws attention. It signals that something is going wrong, not just suboptimal.
And that discomfort has value. It speaks not only to clinicians and managers, but to finance directors, policymakers and the public. And it is having a critical mass of people bought in to the problem that often holds the key to unlocking meaningful change.
