This article is an adaptation of a June 2026 blog by AACE Managing Director Anna Parry, which was posted on the NHS Strategy Unit’s website.
Failure demand is described as the additional work created when services fail to meet people’s needs effectively the first time – and it is rife across the NHS.
The ambulance service has historically picked up a significant amount of failure demand, acting as what is often described as a backstop or safety net, perpetuated by its 24/7 presence and availability. Through the realisation of 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 Unit’s compelling 2026 article, Failure demand as a route to success?, demonstrates that the concept of failure demand could indeed help improve the NHS. It outlines the implications for policymakers, practitioners, 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 that could be managed in the community – “a predictable need met by an emergency response” (p.18).
Most NHS provision has historically been predicated on “in-hours” rather than “out-of-hours” services. This equates to around 33% of the time and five days a week rather than 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 – despite frustrations and recognition of the all-too-frequent sub-optimal nature of the response ambulance services provide – is bad for patients. 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 in the report, 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 – whether they are emergency medical technicians, paramedics, advanced paramedics or prescribing paramedics – and by 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 to which they can refer promptly, the only sub-optimal choice available to them is conveyance to an ED.
This is not good enough. It needs to change.
Ambulance services are rich sources of data. They can 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 by and built in direct response to this and other data, particularly data relating to 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-based support would be more aligned to both their immediate and future needs.
Through ambulance services’ provision of 999 call-taking and, around 50% of the time, 111 call-taking (depending on regional or integrated care board commissioning decisions), we receive and are uniquely placed to triage and respond more effectively to emergency and, very often, urgent calls, regardless of whether they come through 999 or some 111 services.
Regardless of the point of entry, the onus must be on the responding service to meet the patient’s need as promptly and appropriately as possible. This calls for a new mode of operating – one where finding the optimal solution for the patient is the priority and commissioning and delivery models are structured around that.
We must flip what has gone before. Too often, patients have had 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 ideal 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.
