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‘Hear and treat’ generally refers to the scenario when 999 calls are provided with a response that does not involve dispatch of an ambulance vehicle. Ambulance Quality Indicators available in England show variation across organisations in the amount of ‘hear and treat’ and in the amount of re-contact in 24 hours. However, little is known about variation in the process of ‘hear and treat’. The aim of this qualitative research was to understand more about organisational variation in ‘hear and treat’.Three ambulance services with deviance from the average amount of ‘hear and treat’ and re-contact in 24 hours were recruited. Non-participant observation was conducted to explore the process involved in both initial call assessment and enhanced clinical assessment. This entailed 40 hours of observation in each organisation (total n=20 call-handlers and 27 clinicians) and semi-structured interviews with call-handlers (n=7), clinicians (n=7) and managers (n=3). A framework approach and NVIVO qualitative data analysis software were used in analysis of the data.The findings identified variation around skill mix, role, environment and processes across the three ambulance services that may be factors contributing to variation in the amount of ‘hear and treat’. Commonalties were identified in relation to decision criteria, barriers and frustrations around delivery of appropriate hear and treat responses, for example, patient expectations, communication, information and access to services. Apparent facilitators were also identified, for example, specialist clinicians in mental health.This research contributes to understanding the nature of ‘hear and treat’ in different ambulance service contexts and the potential reasons for variation in ‘hear and treat’ rates and re-contact rates. This knowledge is important to inform service delivery and management of the increasing demand for urgent and emergency care.