One year ago, the government published its Elective ReformPlan – the most detailed blueprint for tackling NHS waiting lists that we’veseen in a generation. It was ambitious. It was well-structured. And it set aclear direction: 92% of patients waiting no longer than 18 weeks from referralto treatment by March 2029.

Twelve months on, the headline numbers tell two very different stories depending on where you look. And for those of us working inside the system, it’s the tension between those stories that matters most.

The good news is real – and it deserves recognition

Let’s start with what’s working, because the peopledelivering it deserve credit.

The NHS delivered 18.4 million elective treatments andoperations in 2025 – the highest figure in its history. That’s up from 18million in 2024. The overall waiting list has dropped to 7.29 million, the lowest level since February 2023. The proportion of patients waiting over 52weeks has fallen to 1.9%, and the Further Faster 20 programme – which deployed specialist teams into 20 trusts with the highest levels of economic inactivity– saw those trusts cut their backlogs three times faster than the national average.

These are not trivial achievements. They represent real patients getting real treatment, often delivered by teams working under extraordinary pressure alongside the busiest winter on record for emergency departments.

But the targets are slipping – and that tells us something important

Here’s where it gets more complicated.

The Elective Reform Plan set interim targets for March 2026:65% of patients should be within 18 weeks, every trust should deliver 5 % point improvement, and waits over 52 weeks should fall below 1% ofthe total list.

As of the latest data, national performance sits at around 61.5% against the 18-week standard. The Health Foundation’s analysis suggests that if current trends continue, we’ll reach roughly 63.4% by March – narrowly missing the 65% target. More concerning, only 54 of 144 trusts (38%) are currently on track to achieve the 5 % point improvement. And the 52-week position, at 2.2% projected, is well above the 1% ambition.

Now, missing an interim target by a percentage point or two isn’t a crisis in itself. But it does raise a question that we think is more important than the headline numbers: is the current approach sufficient to deliver sustained improvement, or are we reaching the limits of what the existing model can achieve?

Demand continues to outpace supply – and that’s the structural challenge

This is the figure that doesn’t get enough attention. In December 2025, 1.43 million cases were managed on the waiting list. But 1.64million new cases were added. Demand is still outstripping activity, month after month.

The King’s Fund has noted that more patients continue to join the waiting list each month than receive treatment, and that while this remains the case, it will be difficult to make significant inroads into either waiting times or total list size. The recent reduction in the overall list has been driven in large part by the removal of patients who, for various reasons, should no longer have been on it – important work, but not the same as treating more people.

We see this in our work across NHS organisations every day. Trusts are working harder than ever, but the maths doesn’t change: if demand growth outpaces capacity growth, the list will not sustainably reduce. And crucially, the national data doesn’t always tell you where in the pathway that imbalance sits.

What this means at trust level – where the real work happens

National statistics are useful for political accountability. But waiting lists are not managed nationally. They’re managed specialty by specialty, pathway stage by pathway stage, at individual trust level.

This is something we’ve consistently advocated: the focus needs to be at a much lower level of detail than most recovery programmes currently operate. Not just at ICB or provider level, and not just at individual service level, but at individual waiting list and pathway stage.

When the 18-week standard was introduced, it was broadly understood that most pathways would need to conform to a three -phase ‘6-6-6’week timeframe – approximately 6 weeks each for first outpatient appointment, diagnostic tests and treatment. That framework remains a relevant yardstick today. But it requires trusts to understand, for every key specialty:

• What is the sustainable waiting list size at each pathway stage?

• How far beyond sustainable are we right now – and how much additional activity is needed for recovery?

• Are ongoing capacity and demand in balance, so the list doesn’t simply grow back?

Without this level of granularity, recovery plans become spreadsheet exercises – trajectories that look plausible on paper but have no resilience when a consultant goes on leave, when outsourcing underdelivers, or when winter pressures consume elective capacity.

Data quality remains the uncomfortable foundation

There’s a reason we keep coming back to this, and it’s not because we’re a data quality improvement consultancy (though we are). It’s because every recovery plan is only as good as the data it’s built on.

The Health Foundation’s recent work on linked elective care data was striking in its candour: data relating to the waiting list often have substantial limitations and quality issues, which hamper the ability to effectively manage waiting times. Clock start errors alone can distort a trust’s 52-week position by 10–15%. Patients ‘pop on’ at 65 weeks not because they suddenly appeared, but because they were lost to view earlier in the pathway – a milestone drifted, a referral was misrecorded, an assumption went unchecked.

Having validated over 2.5 million patient pathways across 22+ NHS organisations, we’ve seen this pattern repeatedly. The trusts that make fastest progress aren’t necessarily the ones with the most resources. They’re the ones willing to confront the quality of their data before building plans on top of it.

Looking ahead: what the next twelve months need to look like

The Elective Reform Plan was the right starting point. But a plan is only a plan. As we enter the second year, we’d argue the focus needs to shift in three important ways.

First, from national metrics to pathway-level intelligence. Aggregate numbers mask enormous variation between trusts, between specialties, and between pathway stages. Recovery that works needs to be planned and monitored at the level where the bottlenecks actually exist.

Second, from activity volume to demand-capacity balance. Delivering record treatments is important, but it’s not enough if referrals continue to grow faster. Sustainable recovery requires a plan for both sides of the equation – including honest conversations about referral management, advice and guidance and pathway redesign.

Third, from assumed data to validated data. Every trust should know, with confidence, how accurate their PTL is before committing to a recovery trajectory. The cost of building a plan on unreliable data is not just wasted effort – it’s clinical risk for the patients waiting in the gaps.

The bottom line

Year one of the Elective Reform Plan has delivered genuine progress. The people working in the NHS to make that happen deserve recognition and support, not just scrutiny.

But progress and sufficiency are different things. The targets being missed are early warning signs, not failures. Whether they become failures depends on what happens next – and whether the system is willing to do the harder, less visible work of fixing the foundations rather than just increasing the throughput.

The trusts that recover fastest won’t be the ones with the best slides. They’ll be the ones willing to admit the slides aren’t working.

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