The problem over the use of accident and emergency departments is portrayed in terms of a typical conflict between professional and lay needs. However, in contrast with the more common image of the professional hospital doctor successfully developing both structural and interactional strategies for maintaining professional dominance over the patient, it is argued that the structural characteristics of the accident and emergency department pose control problems for the profession. These control problems have been exacerbated by developments in other areas of the health service and have led to the development of policies which emphasize both clinical and social elements of patient need. Although there is apparent recognition by providers of the importance of taking into account patient need, the proposed policies are based on professional images of how patients ‘ought’ to use the service. What is clearly lacking is comprehensive data on how the public and the community wishes to use the service and how they actually use the service. Data from national and local studies on patient felt needs and patient demand for the hospital accident and emergency departments are presented and the implications for policy are discussed.