Failure demand is described as the additional work created when services fail to meet people’s needs effectively the first time – and is rife across the NHS.  

The ambulance service has, historically, picked up a lot of failure demand acting as, what is often described as a back-stop or safety net, perpetuated by its 24/7 presence and availability. Through the realisation AACE’s vision and offer across urgent and emergency care, we are advocating a commitment to the reduction, and ultimate eradication, of failure demand by better meeting patient need through a clinically appropriate and timely response at the point of first contact.

The Strategy’s Unit 2026 Could the concept of failure demand help improve the NHS? compelling demonstrates that the concept of failure demand could indeed help improve the NHS. It outlines the implications for policy makers, practitioners and system leaders and researchers. 

The report includes one example of failure demand that ambulance services play a part in: ventilated patients being admitted via ambulance for routine catheter changes manageable in the community: ‘a predictable need met by an emergency response’ (p.18).

Most NHS provision has historically been predicated on ‘in-hours’ as opposed to ‘out-of-hours’ services. This equates to around 33% of time, and five days a week as opposed to seven. Combined, this equates to around 23% of the time. This means that, remarkably, service provision for around 77% of the time is designed and delivered sub-optimally. 

This inevitably – and obviously - gives rise to failure demand: additional activity is generated because patient need is not met appropriately when it initially presents. 

The historic ambulance service model has, arguably, perpetuated this failure demand. The tendency to accept and tolerate it - in spite of frustrations and recognition of the all too frequent sub-optimal nature of the response ambulance services provide – is bad for the patient. It is also bad for the system. 

The term ‘cracking a nut with a sledgehammer’ springs to mind when, in the (catheter change) example featured, the equivalent of a mobile Emergency Department (ED) unit crewed by two clinicians is used to convey someone to hospital.

Ambulance clinicians are constrained by their scope of practice – be they an emergency medical technician, paramedic, advanced paramedic, or prescribing paramedic – and the availability of alternative pathways. If they are not equipped with the skills and experience to change a catheter, and there is no community or general practice alternative that they are able refer to promptly, the only – sub-optimal – choice available to them is conveyance to an ED. 

This isn’t good enough. It needs to change.

Ambulance services are rich data mines. They are able to determine, predict and project service need, demand and presentations across urgent and emergency care.  Service design and delivery, across the urgent and emergency care system and not just within ambulance services, should be informed and built in direct response to this, and other, data and specifically patient presentations and need. 

Responding to failure demand perpetuates failure demand. Patients are avoidably conveyed to EDs being picked up - and progressed through acute, in-hospital pathways - when an initial community response and subsequent community responses would be more aligned to both immediate and future patient need.

Through ambulance services’ provision of 999 call-taking and about 50% of the time (depending on regional or integrated care board commissioning decisions) 111 call-taking, we receive, and are subsequently uniquely placed, to triage and respond to emergency and very often urgent calls (that come through either 999 or some 111 services) better. 

Regardless of which entry point, the onus must be on the responding service to meet their need as promptly and appropriately as possible. This calls for a new mode of operating – where finding an optimal solution for the patient is the priority and commissioning and delivery models are structured around that. 

We must flip what’s gone before. Too often patients have to orbit around arbitrary and obstructive organisational boundaries or professional silos. Instead, we, as an integrated and co-ordinated NHS, must orbit around the patient. 

Ambulance services’ unique – and very privileged position – in the urgent and emergency care sphere places them in an optimal position to act as care co-ordinators or navigators responding to patient need in a timely and appropriate way. 

The acceptance and perpetuation of failure demand must cease.

Anna Parry is Managing Director of the Association of Ambulance Chief Executives