NHS waiting lists are falling. The transformation programme paying for it is only half built.

England’s NHS hit a real target this year: 65.3% of patients started treatment within 18 weeks by March 2026, up from 59.8% a year earlier. The waiting list has fallen from a peak of 7.75 million in August 2023 to 7.12 million by February 2026, having grown from around 4.4 million before the pandemic. Against a decade in which the 92% constitutional standard hasn’t been met since 2015, a government and NHS leadership under sustained pressure can reasonably claim the recovery is working. That claim holds up. What doesn’t hold up is the assumption underneath it: that the transformation programme funded to make this recovery durable is what actually delivered it.

Two different numbers moving at once

Look under the headline fall and two mechanisms are doing the work, and only one of them is treatment. NHS England’s own guidance on recording RTT waiting times defines a category called unreported removals: pathways cleared through validation exercises checking for duplicates and errors, patients struck off after failing to respond to appointment offers, and referrals timed out automatically after 180 days unresolved. Nuffield Trust’s analysis of the underlying NHS England data found that between April 2023 and March 2025, trusts removed an average of 244,578 pathways a month this way, without a patient being treated: roughly 3% of the entire waiting list, cleared without treatment, every month.

Set that beside the actual net change in the list. It fell by about 630,000 between the August 2023 peak and February 2026, a period of 30 months, or roughly 21,000 a month. Monthly unreported removals ran at more than 11 times that net monthly fall. Meanwhile the completion-to-referral ratio, the number of pathways finished for every new one opened, stood at 0.86:1 in May 2025, Nuffield Trust found. More people are still joining the list each month than are leaving it through treatment. The list is falling. Genuine treatment throughput hasn’t caught up with demand.

Where the transformation money actually went

NHS England has spent over £3.2 billion since 2022-23 on the programmes meant to make that throughput real: £2.2 billion on diagnostic transformation, including community diagnostic centres, and just over £1 billion on surgical hubs built to run day-case procedures at higher volume. The National Audit Office’s March 2025 review of that spending found 141 of 170 planned diagnostic centres open, with 22% of patients still waiting over six weeks for a test against a 5% target; 19 of 37 surgical hubs complete, with 11 behind schedule; and, among the 44 hub trusts that reported figures against their own plans, additional elective activity running 48% below what they had committed to deliver between April 2023 and September 2024. A separate £52 million spent redesigning outpatient pathways aimed to cut follow-up appointments by 25% against 2019-20 levels; it achieved a 0.1% reduction. Across the whole elective recovery effort, activity in 2024-25 reached 116% of the pre-pandemic baseline, against a 129% target. The programme built to change how care is delivered is running at roughly half pace on its own numbers.

The patch that’s being switched off

So what filled the gap between a transformation programme running at half pace and a waiting list that fell anyway? Largely, paying more for the model the transformation was meant to replace. NHS trusts spent just under £10 billion on temporary staffing in 2023-24, including premium-rate waiting list initiative sessions and agency and bank shifts to run extra clinics and theatre lists outside core hours, according to NHS Confederation’s analysis of trust finances, the only breakdown available at this level of detail; that fell to £8.3 billion in 2024-25, still a large sum bought at a premium over core-hours delivery. NHS England’s own 2025/26 planning guidance now instructs providers to hit “close to 100%” of planned core capacity before accessing any premium capacity at all, and to cut agency spend by a minimum of 30% and bank spend by 10%, while still finding 4% productivity gains against a 1% cut to cost base. That isn’t a technical footnote. It’s NHS England withdrawing, on affordability grounds, the funding mechanism that has done a large share of the work behind the last two years of headline recovery, in the same year its own transformation programme is still under-delivered on hubs, diagnostics and outpatient redesign, by its own auditor’s figures.

The honest reading of the data isn’t that NHS elective recovery is fake. The 65.3% figure, and the fall from 7.75 million, are real. It’s that the recovery has run mostly on data cleansing and expensive overtime, not on the transformation programme the money was meant to buy, and the overtime tap is now being turned down before the transformation catches up. For anyone running a delivery programme against a hard external target, the lesson travels well beyond healthcare: a metric can move for a year or two on spend and administration long before the underlying capability meant to sustain it actually exists, and the two need tracking separately, because only one of them survives a budget reset. NHS England’s own goal of returning to 92% compliance by 2029 depends on surgical hubs, diagnostic centres and redesigned pathways that are, on the regulator’s own figures, running at roughly half of what was planned. Unless that delivery gap closes faster than it has over the past three years, the next stage of the recovery has considerably less road behind it than the last one did.

Sources

• NHS England, Referral to Treatment (RTT) Waiting Times statistics and Recording and Reporting RTT Waiting Times guidance (v5.0, February 2025)
• NHS England, 2025/26 Priorities and Operational Planning Guidance
• National Audit Office, NHS England’s management of elective care transformation programmes, March 2025
• Nuffield Trust, “Why is the planned care waiting list coming down and what does the data really tell us?”
• Nuffield Trust, “Elective (planned) treatment waiting times”
• NHS Confederation, The state of NHS finances 2024/25
• House of Commons Committee of Public Accounts, “Reducing NHS waiting times for elective care”