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Background The Urgent and Emergency Care system in England faces increasing pressure, leading ambulance services to support care outside Emergency Departments (EDs) through on-site treatment, community services, and phone advice. However, these initiatives vary by region and are constrained by workforce and system capacity. National strategies, including the Urgent and Emergency Care Recovery Plan and NHS England’s 2024/25 priorities, advocate for shifting care from hospitals to the community, supported by integrated coordination to reduce avoidable ED visits and admissions.Aim This study aimed to identify factors contributing to declined referrals through alternative-to-ED pathways for North West Ambulance Service (NWAS) patients, informing service evaluation and quality improvement.Methods A retrospective observational study examined declined referrals to five external provider services in one locality, using data from the NWAS Electronic Patient Record between 1st September and 31st December 2024. The anonymised dataset included reasons for declined referrals, patient demographics, clinical scores, crew interventions, and final patient outcomes.Results Seventy-five declined referrals were reviewed. Just over half (51%) were redirected successfully via second referrals, while 25% were conveyed to ED despite meeting criteria for alternative services. Most patients were elderly and moderately to severely frail, though frailty was often poorly documented. Many had low acuity and required no clinical intervention, yet conveyance to ED remained common, especially for Health Care Professional (HCP) admissions.Conclusion Many low-acuity patients were potentially unnecessarily conveyed to ED due to fragmented pathways, limited alternatives, and risk-averse decision-making. Systemic barriers, poor documentation, and lack of service integration further contributed to underuse of alternative care options, highlighting the need for improved coordination, referral processes, and access to community-based care.