email received by castle hill hospital on 26/08/26~5pm I am writing to inform you that the NHS Wales Joint Commissioning Committee (NWJCC) has placed the Cardiff and Vale University Health Board (CAVUHB) Welsh Gender Service (WGS) into Level 3 Escalation with immediate effect. The executive lead for the escalation process is Professor lolo Doull, Medical Director, NWJCC. As part of this escalation, the following actions have been directed with immediate effect: 1. All referrals from the Welsh Gender Service for NHS England commissioned gender affirming surgery are to be paused. 2. All surgical assessments and gender affirming surgeries for Welsh Gender Service patients already referred to NHS England commissioned providers are to be paused. 3. No further surgery should proceed for Welsh Gender Service patients until the NWJCC.confirms that the pause has been lifted. Could you please ensure that all members of your team are notified that these arrangements take effect from today (26/08/2026), The pause will remain in place until the NWJCC is assured that appropriate clinical govemance, assessment and referral processes are in place within the Welsh Gender Service An urgent Independent Clinical Review of patients currently on surgical waiting lists is being commissioned jointly by the NWJCC Medical Director and the CAVUHB Medical Director. In parallel, CAVUHB is establishing arrangements to communicate the pause with affected patients, and to put support in place, including a dedicated helpline. This action has been taken following concerns arising from referral data from 25/26 indicating significantly higher rates of referral for gender affirming surgery from the Welsh Gender Service compared with English gender services. GDNRSS data showing substantially lower progression rates to masculinising genital surgery for WGS referrals compared with English gender services; and concems regarding the appropriateness of some referrals received from the Welsh Gender Service. While we recognise the significant waiting times already experienced for surgical assessment and treatment, we feel that a temporary pause is the safest and most proportionate action pending completion of the independent Clinical Review, and until such point that we have assurance of clinical governance via CAVUHB. Please acknowledge your receipt and dissemination of this email by return.