Solving the elective problem starts with understanding it.
For years, the national conversation around elective recovery in the NHS has focused almost exclusively on the most visible symptom of the problem: patients waiting the longest for treatment. While these headline-grabbing metrics, particularly around those waiting over 52, 65 or 78 weeks, highlight an important issue, a disproportionate focus on the backlog has obscured the real challenge – where delays first take root.
But we are looking at the wrong end of the issue.
Enter the frontlog: patients who have been referred into the NHS for elective care by their GP but have not yet had their first clinical contact.
“First clinical contact” refers to the initial interaction between a patient and a healthcare professional for the assessment, diagnosis, or treatment of a health issue. It is the starting point of a patient’s journey through the healthcare system for a particular condition. Those who are classed as completely unseen are waiting for this – referred but in the dark, and often with no information, no visibility, and no clear sense of what happens next. They are unseen, unmeasured, and largely unaddressed.
This is an area MBI has noticed getting worse when working to reduce waiting list sizes, yet is not the focus of recovery priorities. But for as long as patients continue to wait for 18+ weeks just to be seen for the first time, there will always be long waiters. The frontlog is the upstream cause of downstream strain, and it has gone unchallenged for too long.
It is critical that there is a shift the mindset to the way we approach elective recovery. There must be movement from a reactive clean-up operation to a proactive and preventative strategy. By identifying and addressing the frontlog, the system can intervene earlier and reduce deterioration. This is how we restore flow, protect clinical capacity, and rebuild public trust in the healthcare system.
Delays to first clinical contact
New analysis by MBI Health suggests that the issue of the frontlog is far more widespread than generally recognised. Around 70% of all open Referral to Treatment (RTT) pathways — approximately 5.08 million out of 7.27 million – fall into this category of being entirely ‘unseen’. Based on there being approximately 0.84 patients per pathway, and accounting for data inaccuracies up to 30%, this represents an estimated 2.99 million people waiting for their first clinical contact.
Delays to first clinical contact represent a systemic structural issue. Because the RTT framework measures waits from referral to treatment as a single metric, the critical delay between referral and the first clinical interaction is not recorded, and is therefore masked. As a result, until now there has been little visibility into where delays first take root, and therefore little chance to tackle them.
In many trusts and specialties, the median wait to first contact now regularly exceeds 20 – 25 weeks. For certain pathways in particular, such as dermatology, gastroenterology and orthopaedics, waits to first assessment are contributing to late diagnosis, escalation of acuity of presentation, and increased pressure on emergency pathways.
The current approach to elective care is fundamentally reactive: focused on clearing those who have already waited the longest, rather than preventing delays from happening in the first place. When the majority of patients are still waiting to be seen for the first time, the backlog isn’t being reduced, it’s being replenished.
We cannot clear the backlog if the tap is still running.
The data problem: when the numbers are wrong, the decisions are too
A key barrier in elective recovery lies with poor data quality and accuracy. Our analysis suggests at least 450,000 patient records on the RTT list contain data quality errors, preventing an accurate understanding of demand and priorities – and some records might not be in the right place at all. This can include patients who have already been discharged, duplicate entries, or referrals logged to the wrong list altogether. In MBI’s targeted validation exercises, it is often found that over 40% of pathways can be removed upon review.
In some areas, under-reporting is also a problem, as some trusts’ systems do not capture all relevant patient pathways, meaning the true scale of waiting patients may be underestimated in these areas.
The consequences of this flawed data, with misreporting in both directions, are significant, leading to the true picture of the waiting list being obscured. Inaccurate records distort demand, mislead planning, and mask the true patient need. They waste clinical time, obscure real bottlenecks, and make resource allocation inefficient and inequitable.
The NHS has begun to invest in AI-driven safety and performance models – but these tools are only as good as the data they’re built on. This highlights the need for validation as a critical first step in elective recovery, to make the list visible and manageable, facilitating planning with precision and informed decision-making overall.
Specialty breakdown: the biggest challenges
RTT data traditionally captures overall pathway volumes, and it is only by digging beneath the surface that we uncover the scale of first-contact delays within critical specialties. Our new analysis of the waiting list data at specialty level reveals clear hot spots. Across England, five specialties consistently emerge as having the greatest number of patients who have not yet been seen for the first time:
- ENT
- Trauma and Orthopaedics
- Gastroenterology
- Ophthalmology
- Gynaecology and Obstetrics
These specialties are not just statistically significant, they’re also clinically critical. Each represents a high-volume area of care where delayed contact often leads to deterioration in health outcomes. This is a key issue in some trusts where up to 75% of open pathways in these services show no clinical contact at all, with patients yet to progress beyond referral.
To address this, systems must interrogate the causes behind unseen patients in these specialties, and examine appropriate interventions, such as specialty-specific pathway redesign to move from reactive management to proactive resolution.
The consequences: delay becomes deterioration
When people wait months just to be seen for the first time, the consequences ripple across their entire care journey. Delays at this early stage impede clinical triage, prioritisation, and timely diagnostics, leading to unnecessary escalation, missed windows for early intervention, and greater pressure on emergency pathways.
- In orthopaedics, long waits contribute to worsening pain, reduced mobility, and more complex surgical interventions – with losses to quality of life.
- In ophthalmology, delayed first assessments can lead to deteriorations and even irreversible vision loss in conditions like glaucoma or diabetic retinopathy.
- In ENT, symptoms like persistent hoarseness may go unchecked, delaying diagnosis of potentially serious conditions such as head and neck cancer.
- In cardiology, deferred basic evaluations can mean missed opportunities to manage life-threatening conditions like arrhythmias or heart failure.
Across all of these areas, patients waiting without clear communication or timelines can cause significant anxiety, depression, and reduced quality of life due to both physical symptoms, and psychological ones. Timely first contact is critical to prevent this deterioration and improve patient outcomes, as well as install confidence in the healthcare system.
First clinical contact is not simply an administrative milestone. It is the gateway to diagnosis and treatment. Without this initial contact, nothing else can progress. Diagnosis nor decisions can be made, and appropriate treatment cannot begin. This is not about streamlining bureaucracy, but about giving patients the clinical input they need to move forward.
Moving from firefighting to flow: what’s needed for elective recovery
Elective care recovery cannot succeed if it remains focused only on the back of the list. A real opportunity lies in managing the frontlog. By tackling the unseen wait for first clinical contact, the system can reduce deterioration, improve triage, and create a more sustainable healthcare system. This requires a coordinated, system-wide reset:
- Refocus on access to the first contact
Tackling delays to first contact is essential for effective triage, earlier diagnosis, and prevention of unnecessary escalation. Recovery strategies must shift from reactive treatment waits to proactive front-end access.
- Adopt diagnostics-first pathways: streamline care before clinic
By front-loading key investigations before clinic attendance, clinicians can make faster decisions, reduce face-to-face appointments, and shorten RTT times – improving both efficiency and patient outcomes.
- Validate the data: ensure accurate, actionable information
The current waiting list data is unreliable, with errors, duplicates, and omissions across records. Systematic validation is essential to understand the true scale of demand, support fair prioritisation, and enable meaningful planning to truly address elective care recovery.
- Align referrals with capacity: manage demand
Introduce threshold-based referral criteria, dynamic triage, and commissioning support to ensure referrals reflect actual system capacity. This avoids overloading services and ensures patients are only listed when care can realistically be delivered.
- Redesign care delivery: shift treatment out of hospital
Move appropriate care into community, primary, or virtual settings using integrated services, Advice & Guidance, and remote monitoring. This reduces pressure on hospital-based services and improves timely access for high-priority patients.
Conclusion: a strategic reset
Solving the elective care crisis requires more than tackling the visible backlog – it demands a fundamental shift in where and how we focus our efforts. For too long, recovery strategies have centred on prioritising treatment waits while the inflow remains unmanaged, and the front end of the pathway is neglected.
True recovery begins at the point of referral. By improving access to first clinical contact, we can intervene earlier, triage more effectively, and prevent deterioration before it starts. It is here – at the front end of the pathway – that the greatest opportunity lies to improve outcomes, protect resources, and restore patient confidence.
Because the real solution doesn’t lie in chasing the tail of the list.
It lies in transforming the start. Without understanding the elective problem, we’ll never solve it.
