The objective of this study was to examine the effect of two early lactation concentrate build-up strategies on cow performance, fertility and health. The study was undertaken on five Northern Ireland dairy farms, and involved 385 multiparous Holstein-Friesian cows. Cows were allocated to either an ‘Immediate’ or ‘Delayed’ concentrate build-up strategy postpartum. All cows were offered a ‘basal’ diet comprising forage and concentrates (mean, 7.4kg concentrate/cow/day), with a target crude protein (CP) and starch concentration of 145 and 170g/kg dry matter (DM), respectively. An additional 7.0kg of concentrate (mean across the five farms) was then introduced into the diet of each cow, at an incremental rate of approximately 0.5kg/day, over days 1–14 of lactation (‘Immediate build-up’) or over days 21–35 of lactation (‘Delayed build-up’), with the target CP and starch concentration of the total diet being 175 and 200g/kg DM, respectively. While average daily milk yield and fat-plus-protein yield was reduced (P<0.05) during weeks 2 to 5 of lactation with the Delayed concentrate build-up strategy, treatment had no effect on milk yield, milk composition or milk fat and protein concentration over the first 305 days of lactation. Cows on the Delayed build-up strategy produced milk with a higher somatic cell score (P<0.05), while no treatment×time interactions were observed on body condition score during the experimental period. Conception rate to first service was higher with the Delayed build-up strategy (P=0.047), although treatment had no effect on conception to first and second service, calving interval and cows confirmed pregnant during the study (P>0.05). The Delayed build-up strategy tended (P=0.051) to reduce the incidence of fertility related health issues within the first 30 days of lactation, but increased the incidence of mastitis (P<0.05). Treatment had no effect on any other health measures, the reasons that cows were culled, or the stage of lactation when cows were culled (P>0.05). Although concentrate build-up strategy had short-term effects on milk yield and fertility in early lactation, no long term benefits in performance, fertility, health or survival were observed with the Delayed Build-up strategy.