If NHS systems are serious about reducing waiting times, pathway transformation must focus on accelerating diagnosis and clinical decision-making, not simply increasing appointments.
The challenge facing NHS transformation leaders is not a lack of improvement activity. Over recent years, systems have invested heavily in elective recovery programmes, expanded diagnostic capacity, increased clinic activity and implemented a wide range of productivity initiatives. Yet despite these efforts, restoring referral to treatment (RTT) performance remains a significant challenge.
One reason is that many transformation initiatives continue to focus on the visible end of the pathway: outpatient appointments, clinics and treatment capacity.
However, evidence increasingly suggests that one of the greatest opportunities for improvement lies earlier in the patient journey.
According to the Pathway Redesign Playbook: Leveraging Diagnostics to Drive Elective Transformation, the biggest delays in many elective pathways occur before treatment is considered. Patients are often waiting for investigations, specialist review and, ultimately, a clinical decision about the next stage of care.
For NHS operational, innovation and transformation teams looking to make meaningful progress against waiting times, productivity and patient experience objectives, the question is no longer how to deliver more appointments. The question is how to help clinicians reach safe decisions sooner.
Design pathways around decisions
Historically, pathway improvement has often been measured through activity metrics, ie the number of appointments or clinics delivered. These measures remain important, but they are not the outcome patients care about most.
From a patient perspective, the critical outcome is receiving a diagnosis, treatment plan or discharge decision.
The Pathway Redesign Playbook identifies four principles associated with this approach:
- Design for faster decisions – Focus on achieving the earliest safe clinical decision.
- Deliver diagnostics earlier – Bring testing and information gathering forward within the pathway.
- Remove unnecessary touchpoints – Every patient and clinician interaction should add measurable value.
- Digitally enable the entire pathway – Only digital pathways can enable coordinated referrals, diagnostics, collaboration, communication and decision-making at the scale required to transform productivity.
This approach aligns with a growing recognition across the NHS that diagnostics are no longer simply a support function within pathways. They are increasingly becoming the mechanism through which pathways are accelerated. Our work on pathway transformation has demonstrated more than 90% fewer outpatient appointments across multiple pathways and around 8.7 weeks average pathway length with 100% completed within 18 weeks.
However, the playbook warns that current funding and contracting arrangements continue to reward activity within established models of care. It calls on policymakers, commissioners and NHS leaders to develop incentives that reward value and outcomes, enabling diagnostics-first, digitally enabled pathways to move beyond isolated pilots and achieve wider adoption.
Digital infrastructure is essential
Many of the delays observed in elective care stem not from a lack of clinical capacity, but from the operational challenge of moving information between organisations and teams.
Digitally enabled pathways allow referrals, diagnostic information, clinical communications and multi-disciplinary review to occur without relying solely on sequential outpatient appointments. This is particularly important as NHS systems increasingly seek to integrate community diagnostic centres, virtual pathways, and develop neighbourhood care and single point of access models.
Without digital infrastructure that supports timely information sharing and collaboration, it becomes more difficult to significantly reduce pathway length.
Digital pathways delivering results
Drawing on real-world examples from Queen Victoria Hospital NHS Foundation Trust (QVH), the playbook demonstrates how earlier access to diagnostics, digital workflows and clinical collaboration can reduce pathway length, eliminate unnecessary touchpoints and improve productivity. QVH’s digitally enabled insomnia pathway uses patient questionnaires, sleep diaries and remote triage before specialist review.
- 36% of patients were discharged with a management plan.
- 28% were listed for home diagnostic testing.
- 36% were directed to specialist sleep services following alternative diagnoses.
- Patients accessed specialist advice in as little as three weeks, compared with traditional waits of up to 20 to 25 weeks for an outpatient appointment.
The guide also highlights QVH’s award-winning digital breathlessness pathway, where bundled diagnostic testing takes place before outpatient attendance.
- An average active pathway length of five weeks.
- More than 90%: patients discharged back to their GP without requiring an appointment.
The next frontier of elective recovery
The next phase of elective recovery will not be achieved simply by adding capacity to existing pathways. The NHS has already delivered the productivity improvements that it can within traditional models of care. The next opportunity is not to further optimise existing pathways, but to redesign them around faster diagnosis and earlier clinical decision-making.
For organisations seeking to improve RTT performance, increase productivity and enhance patient experience simultaneously, the diagnostics-to-decision interval represents one of the most significant opportunities available.
You can read the Pathway Redesign Playbook and summary version here.
