RA is a chronic disease in which synovitis drives joint destruction. Immunomodulatory therapy in the established phase of disease limits synovitis, and slows the rate of joint destruction, but is not curative. Increasing evidence suggests that the very early phase of RA, within the first few months after the onset of symptoms, represents a pathologically distinct and temporally transient window during which outcomes can be more effectively modulated by therapy. Furthermore, recent data show that we can accurately predict the development of RA in patients with very early synovitis, using clinical and serological measures. This makes very early targeted treatment a realistic possibility. However, it remains the case that the majority of patients with very early synovitis delay for prolonged periods before seeking medical help. Effective public engagement, to reduce this delay, is the key to translate advances in the fields of pathology, prognostication and therapy into benefit for patients with new onset RA.