England’s financial-year-end elective ‘sprint’ got off to a slow start in February, achieving only half the waiting list reduction needed to restore the statutory ’18 weeks’ referral-to-treatment (RTT) waiting time standard by 2029.

Analysis produced for Health Service Journal by Dr Rob Findlay, Director of Strategic Solutions at Insource Ltd and founder of Gooroo Ltd

There is some good news in the mix. The waiting list did come down in February, by 31,000 patient pathways. Improvements were focused on the outpatient and diagnostic waiting list where clinical risk is concentrated. Control was maintained over the costly end of the waiting list, where patients with a decision to admit are waiting for inpatient or daycase treatment. RTT waiting times came down by nearly a week, with sharper improvements in some of the longest-waiting specialties. Overall, the shape of the national waiting list improved. And the improvements were real, not sudden artefacts of throttled demand or ‘validation’ removals.

The problem is, this is all happening far too slowly. The trajectory for ’18 weeks’ success called for a waiting list reduction of 64,000, not 31,000. And that’s for a balanced reduction in the waiting list. Given that outpatients and diagnostics are being tackled first, even faster reductions are needed now to allow enough headroom later to tackle the more complex inpatient and daycase lists.

The shortfall does not disappear – it is carried forward to be tackled in later months. If this was a sprint, then it seems that the athlete was not fully ready for the race.

In the following discussion, all figures come from NHS England. You can look up your trust and its prospects for achieving the waiting time targets here.

The numbers

The current trajectory towards ’18 weeks’ success required the RTT waiting list to fall by 64,221 patient pathways in February. On the typical seasonal pattern the waiting list would have grown by 15,500. So although February’s wait list reduction of 31,006 was less than half the requirement, it was actually a bit better than that because seasonality was overcome too.

The waiting list fell a bit, and the reduction was focused on those patients waiting for outpatients and diagnostics. This is a good thing, because some undiagnosed patients will turn out to have urgent clinical conditions.

As more patients make their way through outpatients and diagnostics, a minority turn out to need admission for inpatient or daycase treatment. They receive a ‘decision to admit’ and are added to the waiting list for admission. This is the costly end of the RTT waiting list, and it is important not to lose control over it otherwise there will be an impossible backlog of resource-heavy treatments to deal with in 2028-29. So it is good news that the overall numbers on this list remain stable.

Waiting times came down by 0.9 weeks in February, both for RTT waiting times overall, and for those patients without a diagnosis and decision to admit. This is what really matters to patients. The goal is to reduce this to 18 weeks by March 2029.

Waiting times are a function of both the size and shape of the waiting list, and the index below is a measure of the shape. It is important not to lose control of this either, and the good news is that it has been improving slightly. It should improve naturally as waiting lists and waiting times come down.

Some of the biggest waiting time reductions were seen in the longest-waiting specialties. Gynaecology, which received government attention this week, edged down to better than Orthopaedics and is now the fifth longest waiting specialty.

We have seen that the waiting list is falling slowly, and the improvement is concentrated in outpatients and diagnostics, with the waiting list for admission remaining stable. There are occasional suggestions in the media that waiting list improvements are not always ‘real’, and caused instead by throttling demand (by avoiding or delaying adding patients to the waiting list), or by deleting patients from the waiting list (through a process of ‘validation’).

Let’s look at demand first. Advice & Guidance is being rolled out and is expected to tighten control over additions to the waiting list. However the data on ‘clock starts’, which is a measure of elective demand, shows that demand has not suddenly reduced and continues to rise slowly year-on-year. So this does not explain the improvement in list size.

The rate that patients were discharged from the waiting list without being admitted for treatment (i.e. mostly from outpatients and diagnostics) increased significantly year-on-year in the February sprint, suggesting a real effort to tackle this part of the waiting list.

This is sensible for several reasons: a) nearly 6 million of the roughly 7 million on the RTT waiting list are waiting for outpatients and diagnostics, so this is where the sheer numbers are; b) an estimated 25,725 of them will eventually receive an unexpected diagnosis of cancer, so it is important to clear the backlog and diagnose them all swiftly; and c) outpatients and diagnostics are relatively inexpensive so it costs less to make a noticeable difference.

When patients reach diagnosis, a small minority will turn out to need admission for inpatient or daycase treatment. They receive a ‘decision to admit’, are added to the waiting list for admission, and after a further wait they are admitted at relatively high cost per case.

Admission rates are low compared with last year, but what is important at this stage is not to lose control over the waiting list for admission while the focus is on outpatients and diagnostics. We saw above that both the size of the waiting list for admission and the overall waiting list shape are stable, so it seems that this is being achieved. At some point, however, the admission rate will need to rise to clear this backlog by 2029.

Finally, is it possible that patients are simply being deleted from the waiting list through ‘validation’? When done properly, validation is a routine process of checking that patients are accurately recorded on the waiting list, and deleting those who should not be there. But sometimes there is a central push to do extra validations, and this causes an uptick in unreported removals from the waiting list.

We can detect unreported removals by comparing the reported additions and removals from the waiting list with changes in list size, and the balance of unreported removals is plotted in the chart below. In April and May 2025 there was a validation drive, and it shows as an uptick in the data. There is no similar uptick in the latest data, suggesting that validation is not the cause of the latest waiting list reduction.

Referral-to-treatment data up to the end of March, and therefore the end of the financial year, is due out at 9:30am on Thursday 14th May. Then we will find out how close the NHS came to achieving its year-end targets following the ‘elective sprint’.