From May 2026, a new incentive comes into play in elective care.
As RTT validation sprint funding begins to taper off, Patient Not Present (PnP) payments are being introduced. At first glance, it looks familiar to the recent validation sprints. A fixed payment per RTT clock stop, tied to reducing waiting lists.
But this isn’t another validation exercise in disguise, but a shift in how decisions are made, and how clinical capacity is used.
What is Patient not Present?
Patient Not Present (PnP) recognises activity where a clinically appropriate decision is made without the patient attending hospital, resulting in a valid RTT clock stop.
In practice, that might mean a clinician reviewing results and deciding to discharge a patient, placing them on active monitoring, or prescribing a course of medication as their treatment and discharging them. The pathway moves forward because a decision has been made, not because an appointment has taken place.
These decisions already happen every day. What’s changed is that they now need to be visible, structured, and counted.
Why this matters
The pressure on elective care is just as much about demand, as it is about how capacity is used.
A significant amount of outpatient activity exists simply to enable decisions that could have been made without bringing the patient back in. That creates avoidable friction in the system. Clinics fill up, patients wait longer, and clinicians spend time on activity that adds limited value.
PnP is therefore a nudge in a different direction.
It encourages organisations to make decisions earlier and more deliberately, using appointments where they are genuinely needed, rather than as a default step in the pathway.
That shift, if done well, creates capacity. And capacity is ultimately what moves waiting lists in the right direction.
Not validation, but still impactful
It’s important not to confuse this with what came before. The previous sprint incentives rewarded retrospective clean-up. Teams went back through pathways and corrected what had already happened.
PnP is different because it is forward-looking. It rewards real clinical decision-making happening in real time.
Waiting lists still reduce, but for a different reason. Patients leave pathways because decisions are made sooner, not because records are being tidied after the fact.
The real challenge: capturing the decision
Where this becomes more complex is not in the clinical decision itself, but in how it is recorded. Most organisations already have clinicians making these decisions. But it is often not captured in a way that feeds RTT reporting or supports reimbursement.
The guidance is clear that the decision date must reflect the point at which the clinical decision was made, and it must align to valid RTT outcomes . If that doesn’t happen, the activity effectively disappears from a reporting perspective.
That creates a familiar gap we see frequently; the work is happening, but the system isn’t seeing it.
And unlike retrospective validation, this is not something that can easily be reconstructed later in most, if not all, EPR systems. If it isn’t recorded at the point of decision, the opportunity is gone.
There is a six week deadline from a PnP activity for this to be recorded in order for it to be eligible for the payments from NHSE.
Where things start to break down
In many organisations, decisions sit in clinic letters or informal workflows before they ever make it into structured data. Outcome coding varies, and the timing of recording doesn’t always match the timing of the decision.
This isn’t going to be a new challenge. From years of validation work across NHS trusts, our validation teams still see missed clock stops linked to decisions made outside of scheduled care activity as one of the most common scenarios.
The issue isn’t the clinical decision but that it isn’t consistently captured.
PnP is designed to change that by incentivising those decisions to be recorded properly, at the point they are made.
A different kind of operational problem
What PnP exposes is a coordination issue.
For it to work properly, clinical behaviour, operational processes, and data recording all need to align. The decision has to move cleanly from clinician to system to report without friction or delay.
That doesn’t require wholesale system change, but it does require some thought about how decisions are captured in real time, and whether current workflows actually support that.
Moving quickly matters
There is also a practical reality. National systems and large EPR providers will adapt to this over time. But that change is unlikely to be immediate, and it will vary by organisation.
In the meantime, some trusts are already taking a more pragmatic approach. Rather than waiting for system updates, they are putting lightweight mechanisms in place to identify, capture, and report PnP decisions as they happen.
We are already seeing examples where this can be layered into existing workflows quickly, whether through local capture mechanisms or enhancements to existing validation and reporting processes . It’s not about replacing core systems, but about making them work for what is needed now.
Those who move early will not just see the financial benefit, but will start to unlock capacity sooner.
Final thought
PnP is being introduced as a financial incentive, but its real impact is operational.
It encourages a move away from using appointments to drive decisions, towards making decisions first and only bringing patients in when it genuinely adds value.
The organisations that get the most from it won’t be the ones who focus on the payment.
They’ll be the ones who use it as an opportunity to rethink how decisions flow through their services, and in doing so, make better use of the capacity they already have.
