Ambulance “frequent fliers” who make several 999 calls a year are costing the NHS in England millions of pounds, with experts concerned that some patients develop an unhealthy pattern of dependent behaviour on the service.

Though most callers have genuine unmet medical needs – few are malicious or hoaxers – the scale of the problem becomes evident as hospital A&E departments get to grips with another winter of rising demands on services. Ambulance service leaders and local health commissioners are keen to focus increasingly tight budgets on patients at more imminent risk.

Among more extreme cases reported by ambulance services are:

A patient who called 999 more than 700 times in two years. The estimated costs to the ambulance service over a year was more than £110,000.



A patient who cost NHS England £10,000 in a month.

A patient who made 238 emergency calls over two months at a cost of nearly £40,000.



The London ambulance service says each patient costs on average £7.81 per 999 call. To be further reviewed on the telephone by a clinician costs £64.59, to receive an ambulance and be treated at home is £155.30, and to receive an ambulance and be taken to hospital costs £254.57.

Frequent callers – a term preferred within 999 services to “fliers” – include people with chronic, often multiple conditions, mental health issues, high levels of anxiety, lack of confidence in managing their own problems, and people who feel socially isolated and may be seeking attention.

Frequent callers are defined nationally as people who make more than five calls in a month or 12 in three months, although figures provided by individual ambulance services are sometimes based on different definitions.

NHS clinical commissioning groups and ambulance services across England have embarked on a programme to change that behaviour. An experienced paramedic at the ambulance dispatch centre helps crews on the scene determine whether they should provide advice on the spot, refer the caller to other services or take them to hospital. This person also phones doctors at GP practices to discuss patients’ clinical conditions and support crews in considering alternatives to A&E.

Louise Lumby, a GP involved in the scheme, said some frequent callers were genuinely very ill. She said: “Telling somebody off doesn’t change behaviour. It is about finding the right service for that patient. I would like to think we have a much better patient journey to care on the back of the fact we have put support in.”

North West ambulance service identified 1,456 frequent callers in 2014-15. “Some patients are unaware of what else to do, or who to ring for help, and although we cannot always provide the care they require, patients know that we will respond”, it said. “Several patients have unmet care needs, are lonely and may have multiple complex needs that necessitate a multidisciplinary approach to support their health and social care needs appropriately.

“Collaborative working and involving the patient in decision making is vital to ensure that patients are involved, that care is personalised and that each care provider is aware of all input. Unfortunately, support offered is not always accepted, and some patients refuse to engage, and will continue to ring 999.”

Rob Cole, consultant paramedic with the West Midlands ambulance service, said the problem was “getting worse in terms of numbers but that is offset by the fact we are considerably better at the management [of the problem]”.

Ambulance services want to focus tight budgets on patients at greater risk. Photograph: Yui Mok/PA

South Western ambulance service received 13,231 calls from frequent callers between June and August 2015. It said: “It is important to acknowledge the difference between inappropriate frequent callers and appropriate frequent callers. For example, a patient with unstable angina, end-stage COPD [chronic obstructive pulmonary disease] or a terminal illness meets the definition of a frequent caller but will have regular contact with us for a genuine acute need.

“We work closely with other agencies, including our GP and hospital emergency department colleagues to jointly manage [them]. Since April 2013, we have only issued eight ‘restricted send’ letters to those frequent callers that we have identified as inappropriate callers that we cannot manage in other ways.”

“Restricted send” letters tell patients that the service would no longer send an ambulance in response to a 999 call “other than in exceptional circumstances where clinical staff believe that your life is in imminent danger”. They also say that having worked unsuccessfully with them and other agencies “we have no other option but to take steps to protect other members of the public who do require our service”.

Jason Scott, a research associate at Newcastle University’s Institute of Health and Society, who previously chaired the frequent caller network, is preparing a case for NHS research into the issues. The number of people calling “to be a nuisance” was small and could be dealt with through the legal process, he said.

But work was needed to identify why others were frequently calling 999, said Scott. “The general agreement is that they are doing so because they have some form of perceived unmet health or social care need and the ambulance call is a fall-back position, the last resort,” he said.

Detailed research was needed on whether cutting the number of frequent 999 callers caused problems elsewhere. Scott said: “Do we simply pass costs on to another part of healthcare, which doesn’t really solve the problem? That would be just passing the buck to someone else.”