What If “Save Ambulances for Emergencies” Campaigns Actually Work?

The campaigns are back. So are the same old problems.

Over the last few weeks, I have seen what feels like a resurgence of an old foe – “save ambulances for ‘real’ emergencies” messaging. Perhaps they never really left. But increased ambulance service pressures resulting from the recent heat waves in the northern hemisphere, coinciding with winter in the southern hemisphere, have recently led to my social media feeds featuring messaging from ambulance services from both ends of the world, reminding me that, as a member of the public, I need to think twice next time I consider accessing emergency healthcare.

Those of you who know me or follow me on social media will already be well aware that I have several issues with this type of messaging and with the general idea that, somehow, health system issues related to increasing system pressure are up to the public to solve by reducing their use. As I have said many times before… why are we blaming users of healthcare systems for using the healthcare system that we provide them?

Issues regarding these campaigns and the overall increase in pressure on healthcare systems that many wealthy countries are facing, especially on ambulance and emergency department resources, are complex – too complex to address in one post.

As such, this post will be the first of a few (at least) addressing the key issues as I see them related to the challenges of increased service demands on ambulance services and emergency departments, what we know about the causes, how low-acuity presentations affect healthcare system pressures and what we can actually do about this.

I plan to present an overview of the key issues surrounding attempts to use public education to reduce emergency healthcare presentations in this post, then, over a series of future posts, unpack the evidence and concepts surrounding this.

Winter is coming, and our ambulance services and emergency departments need “saving” … Again. 

For those of you who aren’t aware of the type of messaging I am referring to, welcome, you must be new, as this is a topic I have been fairly vocal about for several years now (at one point, I think it was all I was known for!) – but the basic premise is as follows:

Step One: An ambulance service or emergency department predicts or experiences increasing pressure on its workload. This may be due to transient external factors, such as an unusual heat wave. It may also be due to a very predictable cycle of increased demand, such as winter surges, that somehow seem to catch health systems by surprise every year like clockwork!

Especially in recent years, though, the trigger may be sustained increases in demand on ambulance services or emergency departments, either due to increased presentations or issues such as ramping and emergency department bed-block.

Step Two: Whatever the reasons, in response to this, either a formal advertising campaign or an informal “plea” from a health executive follows. Regardless of how it is framed, the underlying message is some variation of:

1. The health system is overstretched or at risk of failure due to ‘inappropriate’ presentations
2. It is the public’s responsibility to avoid using these services for anything other than ‘true’ emergencies
3. This is also usually accompanied by an instruction to the public to seek primary care or other community services instead

The general intention here is to use public messaging or education to prevent “inappropriate use” of ambulance services or emergency departments, instead redirecting patients to more ‘appropriate’ ways of accessing care.¹

As mentioned above, I have been vocally opposed to these campaigns for several years due to many reasons, too many to list here concisely. But the fundamental issue I have with this messaging is that it shifts the blame of healthcare system pressure (and in some cases failure) from healthcare system design and delivery, and puts it on the users of that system.

A note on terminology for today’s post: I loathe the term ‘inappropriate presentation’, not least of all because defining an ‘inappropriate’ presentation is problematic. In fact, I would contest that there is no such thing as an ‘inappropriate presentation’, only an inappropriately designed health system. The term also implies a failure on the patient’s part, as if somehow, they should have known that the healthcare service they accessed was the “wrong one”.

Despite this, I use the term ‘inappropriate’ throughout this with inverted commas (to highlight my disagreement with the term), as this is the language most often used, followed closely by ‘avoidable presentation’.

If it is that obvious, why is an ambulance even sent?

A core part of this messaging is that the public should be able to determine for themselves when an ambulance attendance or emergency presentation is required and when it is not. But this raises an important question in the context of ambulance services: if it is that obvious that an ambulance wasn’t required, why was one sent?

Clinical review by a clinician over the phone, often called secondary triage, is used by many (if not most) contemporary ambulance services. This isn’t new, and in some services, a clinician triage process for diverting callers from ambulance attendances has existed for over a decade.² However, secondary triage hasn’t been a silver bullet, and many of these same services still report ‘inappropriate’ attendances.

This isn’t to say there isn’t a role for secondary triage; in fact, my overall argument is the opposite. We need to design the health system so that health professionals can help patients access the care they need, when they need it. Unscheduled telehealth services (whether direct through ambulance services or other means) are an important part of this.

However, in my experience, an ambulance is often still sent to “lay eyes” on the patient and conduct a clinical assessment before a decision is made, either by the attending clinician or jointly with a telehealth clinician, as to whether the patient requires emergency care. Those patients who are not transported may subsequently be labelled low-acuity or non-emergency – i.e., presentations that the public are being told to stop presenting with.

The point here is that if we already have mechanisms to prevent ambulance attendances to non-emergencies, but in several non-emergency cases experienced clinicians (understandably) aren’t willing to take the clinical risk of not sending an ambulance… how can it be reasonable to expect a patient who isn’t a health professional to make this decision?

It is one thing to determine that someone doesn’t need to be in a hospital after a health professional has attended and conducted a thorough clinical risk assessment. It’s a completely different thing to say that the assessment wasn’t needed in the first place. Making that determination after an assessment and calling it an ‘inappropriate’ or ‘avoidable’ presentation is, at best, putting the cart before the horse – it’s much easier to decide with hindsight after an assessment has ruled out the big bad things.

Even with that hindsight, can clinicians retrospectively agree on which patients should have sought care elsewhere? Or put another way, do we, as healthcare professionals, agree on what is an ‘inappropriate’ presentation?

Spoiler alert: we don’t

Health professionals can’t even agree on what constitutes an ‘inappropriate’ presentation, yet we expect the public to figure it out on their own…

Evidence on clinician consensus as to what constitutes an ‘inappropriate’ presentation is clear on two points.

Firstly, almost all clinicians agree that there is a cohort of presentations to emergency health services that would be better managed somewhere else in the health system.^3–7 The usual suspect here is primary care, and these presentations are often labelled as “GP-suitable”.

It is also important to note that just because a presentation may have been suitable for primary care or other healthcare services doesn’t mean the patient had reasonable access to them. One definition of “GP-suitable” is a presentation that is deemed suitable to be seen by a GP within 24–48 hours. I don’t know about you, but I can’t get in to see my GP in anything less than a week, let alone the next day. That’s also before we consider that I am fortunate enough to have the means to pay for unscheduled healthcare if it’s needed.

The second finding from this research is on determining who that cohort actually is. Despite general agreement that there is a cohort of patients who should have sought care elsewhere, when asked to determine which specific low-acuity presentations to an ambulance service or emergency department were ‘inappropriate’, clinicians showed little agreement.^3–7

It may come as little surprise to some that different specialities or professions have differing views on who should be seen in an ED (e.g., GPs and ED physicians). This could be due to differing risk tolerances and expectations, as well as limited understanding of each other’s roles within the health system. But what stands out to me here is that this lack of consensus is also evident among peers and clinicians in the same practice settings.

Similar to my point on health professionals not wanting to take the clinical risk of preventing an initial assessment, if health professionals with years of health education and experience can’t agree on who needs to access these services, even with clinical assessment information, how is it we expect members of the general public to do this?

There is another aspect of this issue that might have more of a consensus, though. When discussing potential solutions or alternatives for low-acuity presentations to ambulance services, the clinicians, policymakers, consumers, and even politicians involved appeared to agree on a key point: messages aimed at reducing such presentations were generally regarded as unhelpful and ineffective.⁸

This begs the question. Do we have any evidence to support that using public messaging to reduce ambulance calls works, and if it does, who stops calling?

The (lack of) evidence behind public messaging to reduce ambulance attendance

Despite ongoing use of “save ambulances for emergencies” messaging and recommendations in several government reports for public education campaigns on the appropriate use of ambulance services, there’s a lack of evidence that these interventions are effective in reducing ambulance demand,^9–11 particularly in the long term.

However, if we also consider the reasons people present to emergency healthcare services with low-acuity presentations, this is hardly surprising. Patients understand that in emergency departments, they’ll be seen in order of acuity, not arrival, despite prevailing beliefs to the contrary among some health professionals.¹² So why do low-acuity patients access emergency healthcare?

Patients who present to these services with low-acuity conditions report a range of very understandable reasons for doing so.^8,12,13 These commonly include believing their concern was urgent, not knowing where else to seek help, or not having access to more suitable alternatives. As a paramedic with extensive experience in delivering and navigating unscheduled care, I have personally encountered situations where I have had no suitable alternatives. In fact, of the three times I’ve attended an ED as a patient since living in Western Australia, two would be classed as ‘inappropriate’ under some definitions.

At the risk of sounding like a broken record, if, as a health professional, I can’t access more appropriate unscheduled care, how do we expect our patients to? 

While there is limited evidence on whether these campaigns might work, if we assume for a moment that they do, we then need to understand who stops presenting. Is it the ‘inappropriate’ presentation, or the person who needs care, and either isn’t aware of alternatives or has limited access to these?

Put more bluntly, do these campaigns cause harm?

The short answer is we know even less about their safety than we do about their efficacy. One study found no significant change in calls for suspected cardiac or respiratory arrest, or in dead-on-arrival cases.⁹ This is unsurprising, and I’d hope no one would let such messaging affect their decision to call an ambulance in such extremis. However, this metric alone is insufficient to assess the potential harms of these campaigns, and the limitations of using such a narrow metric to justify their safety should be obvious to any healthcare professional. The only other study I am aware of that examines a safety metric as an outcome observed reductions in both serious and non-urgent calls. However, it did not directly measure patient harm.¹⁰

While this single study is not conclusive evidence, it should lead us to take very seriously the possibility of very real community harm resulting from discouraging the public from seeking either ambulance or emergency department services.

Final thoughts and comments

If you’re a clinician who needs any further convincing or wants to understand why I’m so passionate about this issue, think back to the last time you asked that nanna, you’ll know the one I mean, why she didn’t call an ambulance or present to the ED earlier and received the all too familiar answer:

“I didn’t want to be a bother, dear, I know you’re all so very busy.”

Which brings me to the biggest concern I have about attempts to reduce calls to ambulance services through public messaging – I’m worried they might work.

As always, stay curious and be excellent to each other.

References

Show References (13)

1.          Borg K, Wright B, Sannen L, Dumas D, Walker T, Bragge P. Ambulances are for emergencies: shifting attitudes through a research-informed behaviour change campaign. Health Res Policy Syst. 2019 Dec;17(1):31. https://doi.org/10.1186/s12961-019-0430-5

2.          Eastwood K, Morgans A, Smith K, Stoelwinder J. Secondary triage in prehospital emergency ambulance services: a systematic review. Emerg Med J EMJ. 2015 Jun;32(6):486–92. https://doi.org/10.1136/emermed-2013-203120

3.          Breen BM, McCann M. Healthcare providers attitudes and perceptions of ‘inappropriate attendance’ in the Emergency Department. Int Emerg Nurs. 2013 Jul;21(3):180–5. https://doi.org/10.1016/j.ienj.2012.08.006

4.          Cummins NM, Barry LA, Garavan C, Devlin C, Corey G, Cummins F, et al. Clinician consensus on “Inappropriate” presentations to the Emergency Department in the Better Data, Better Planning (BDBP) census: a cross-sectional multi-centre study of emergency department utilisation in Ireland. BMC Health Serv Res. 2023 Sep 18;23(1):1003. https://doi.org/10.1186/s12913-023-09760-6

5.          Gill JM, Reese CL, Diamond JJ. Disagreement Among Health Care Professionals About the Urgent Care Needs of Emergency Department Patients. Ann Emerg Med. 1996 Nov 1;28(5):474–9. https://doi.org/10.1016/S0196-0644(96)70108-7

6.          Prendergast C, Ryan J, Barry LA, Galvin R, Cummins NM. Consensus between healthcare professionals on the “appropriateness” of attendances in an Irish emergency department. Ir J Med Sci. 2025 Jun;194(3):1149–54. https://doi.org/10.1007/s11845-025-03961-0

7.          Richardson S, Ardagh M, Hider P. New Zealand health professionals do not agree about what defines appropriate attendance at an emergency department. N Z Med J. 2006;119(1232).

8.          Wilkinson-Stokes M, Yap C, Crellin D, Bange R, Braitberg G, Gerdtz M. How should non-emergency EMS presentations be managed? A thematic analysis of politicians’, policymakers’, clinicians’ and consumers’ viewpoints. BMJ Open. 2024 Jul;14(7):e083866. https://doi.org/10.1136/bmjopen-2024-083866

9.          Borg K, Dumas D, Andrew E, Smith K, Walker T, Haworth M, et al. Ambulances are for emergencies: shifting behaviour through a research-informed behaviour change campaign. Health Res Policy Syst. 2020 Jan 23;18(1):9. https://doi.org/10.1186/s12961-019-0517-z

10.        Ohshige K. Reduction in Ambulance Transports during a Public Awareness Campaign for Appropriate Ambulance Use. Acad Emerg Med. 2008 Mar;15(3):289–93. https://doi.org/10.1111/j.1553-2712.2008.00044.x

11.        Hou X, Zhao J, Chu K. Impact of a government triple zero awareness campaign on emergency department patient characteristics. Emerg Med Australas. 2012 Aug;24(4):393–400. https://doi.org/10.1111/j.1742-6723.2012.01560.x

12.        Janerka C. Patient experience of emergency department triage: An integrative review. Int Emerg Nurs. 2024 May; 74:e101456 https://doi.org/10.1016/j.ienj.2024.101456  

13.        Booker MJ, Shaw ARG, Purdy S. Why do patients with ‘primary care sensitive’ problems access ambulance services? A systematic mapping review of the literature. BMJ Open. 2015 May;5(5):e007726. https://doi.org/10.1136/bmjopen-2015-007726