Betsi Cadwaladr University Health Board: external rapid review of referral to treatment (RTT) data integrity and governance

In November 2025, the Welsh Government commissioned an external rapid review of data integrity and governance for referral to treatment (RTT) statistics within Betsi Cadwaladr University Health Board.

This followed the suspension of published referral to treatment (RTT) statistics for Betsi Cadwaladr University Health Board due to anomalies and inconsistencies in reported waiting list data.

The review examined governance, technical processes, coding issues, and assurance mechanisms across the organisation and the wider national system.

The review confirms that handling of a specific data code resulted in anomalies in reporting. Betsi Cadwaladr University Health Board has now strengthened its monthly governance framework, introduced improved reconciliation and sign‑off procedures, and corrected historical data cases back to April 2025.

The review also confirms that the omission of a specific data code from aggregate reporting resulted in under-coverage in the official statistics, though when this code was subsequently included a small amount of over-coverage resulted initially. The health board has now corrected historical data back to April 2025. Improvements to routine quality assurance and sign-off procedures have also been made, and its monthly governance framework has been strengthened.

The review raises an opportunity to look at what non-consultant coding arrangements should be at an all-Wales level. This is not related to the underlying cause of the recent data issues in Betsi Cadwaladr University Health Board, but should be taken forward nationally to provide confidence that data standards are applied consistently across Wales.

By 19 December 2025, Betsi Cadwaladr University Health Board had submitted revised RTT files for April to November 2025 to Digital Health and Care Wales (DHCW) which were loaded through national systems, with Welsh Government Knowledge and Analytical Services (KAS) reviewing them ahead of publication timelines. Data were processed by Welsh Government statisticians to prepare for publication of revised and updated data at the earliest opportunity, in line with the Code of Practice for statistics.

The Office for Statistics Regulation (OSR) has endorsed the actions taken in response to the data issues, which have enabled accurate and reliable reporting to be published on 13 January 2026.

Patient activity was recorded accurately within the Patient Treatment List (PTL) at all times, with no impact on patients’ treatment. The required strengthening of the reconciliation process for reports generated from the weekly and monthly PTLs has been enacted and the issue and processes shared with other providers and the national team to strengthen overall accuracy of reporting of performance across NHS Wales.  

Clear recommendations are made for Betsi Cadwaladr University Health Board and for NHS Wales to strengthen processes.

This report summarises the findings of the external rapid review commissioned to understand and address issues affecting the accuracy and governance of RTT reporting at Betsi Cadwaladr University Health Board. It draws on documentation, technical analysis, and three formal review meetings held between the review team and the health board.

The purpose of the review was to:

• assess the accuracy, completeness and governance of RTT data submitted by Betsi Cadwaladr University Health Board
• identify technical and procedural root causes behind data anomalies
• ensure compliance with national RTT reporting standards
• restore confidence in official statistics
• recommend improvements both locally and nationally

The review was led by Welsh Government with representation from:

• Health Social Care Early Years (HSCEY) Delivery and Performance team: performance assurance
• Digital Health and Care Wales (DHCW): technical validation and file‑processing
• Welsh Government Knowledge and Analytical Services (KAS): data integrity, and public confidence in statistics
• NHS Wales Performance and Improvement (NHSP and I): system assurance and benchmarking
• Cwm Taf Morgannwg University Health Board (peer representative): comparative insight and operational challenge

DHCW and KAS also provided system‑level assurance on file loading, validation checks, and national trend comparison processes.

As part of a national initiative to improve access for first outpatient appointments, high volumes of patients were scheduled to be seen in September 2025 by an external provider. As a way of identifying patients to be seen under this initiative, the health board changed the pathway clinician code to a generic code (CONSG) that is used when the lead clinician for a pathway of care is not yet known. 

The daily management information and weekly reporting of patients waiting for treatment correctly included these patients. However, they were omitted from month end RTT data due to an error in the reporting process that excluded the CONSG code.

The unusually high volume of patients transferred to the CONSG code and subsequently excluded highlighted to the Data, Intelligence and Insight team that there was a difference between weekly reports and the September 2025 month's end position. 

The error was potentially masked by expectations of significant reduction in the September numbers waiting due to increased activity undertaken and a lack of triangulation in the reconciliation process. National reconciliations of weekly and monthly reported performance did not highlight the issue.

A correction to the health board’s reporting process was made to ensure all pathways were included in the October month's end reports. Whilst the October submission was made on time and correctly included these patients, nationally the movement between September and October 2025 was flagged as a data anomaly as overall patient waiting numbers increased. 

Governance and assurance gaps

Evidence from the health board’s response confirms that earlier processes require improved governance checks and clear escalation routes.

Key gaps included:

• insufficient triangulation between operations, information and performance teams
• immature reconciliation processes
• validation comments often minimal at national submission stage
• executive oversight not fully embedded into the reporting cycle when there were periods of leave

Technical Issues (CONSG, EGU, SDEC, Trauma)

The CONSG code is used by the health board to identify cohorts of patients where the clinician that will provide care is not yet known. This code was omitted from month's end summary reports due to an error in the setup of the code and its management in the reporting processes. The error was corrected for October’s reporting to include all pathways recorded against this code.

The review found that whilst the mis‑handling of CONSG coding initially caused unintended under-reporting of pathways for the months of April to September the correction made in October caused over-reporting. 

Analysis of all pathways recorded with the CONSG code was undertaken and identified three cohorts of over-reporting:

• Early Pregnancy Assessment (EGU)
• Same Day Emergency Care (SDEC)
• Trauma clinics

These cohorts are associated with non-elective pathways and therefore not reportable within RTT. Pathways were validated and manual corrections made where appropriate. 

Manual corrections for April to November 2025 were required and have now been applied by the health board’s digital team.

Non‑Consultant (NC) Coding

In assessing compliance with RTT reporting standards, the review raised the question of how appropriate consultant and non-consultant pathways are defined and identified for reporting. It was agreed that:

• NC pathways are, with some exceptions, out of scope of RTT reporting
• the definition of pathways in scope of RTT reporting is a broader all‑Wales data standards issue requiring national review
• any review into RTT reporting coverage should be taken forward separately at a later date and this matter would not delay BCUHB resubmission or publication timelines

System-Level Checks (DHCW and KAS)

Key system-level insights include:

• DHCW performs load checks (file rejection rules) and validation warning checks
• validation warnings require health board sign‑off; comments are often minimal
• KAS conducts analysis of trends, consistency and data validity:
  • the anomaly was ultimately identified through comparison of official monthly data with weekly management information
  • this was not a standard part of regular KAS quality assurance but has since been integrated into routine processes
• national teams will strengthen trend‑comparison checks going forward

All‑Wales learning indicators

All-Wales learning includes:

• Trend patterns in NHS activity in the current reporting year have been highly unusual, making typical variance‑detection less sensitive.
• Daily RTT validation by other health boards was highlighted as best practice. For example, Swansea Bay University Health Board runs daily internal RTT reporting.
• All health boards have been reminded to improve month‑to‑month scrutiny.

Actions Taken to Date

Betsi Cadwaladr University Health Board has taken action to strengthen local governance including: 

• adoption of a strengthened standard operating procedure (SOP) covering days 9 to 10 of the cycle, executive sign‑off, and validation flows, including triangulation between information, performance and operational teams
• introduction of a reconciliation template (record counts, deltas, adjustment logs)
• formalised communication and input to the development of standard operating procedures between Digital, WPAS, operational teams, and performance leads

National action has been taken to provide technical assurance, including:

• detailed walkthrough of SQL logic with DHCW and NHS Performance and Improvement representatives
• confirmation that no manual pathway level alterations occur outside of month‑end validation processes
• manual corrections have been applied for April to November 2025
• revised files for April to November 2025 submitted and loaded by DHCW
• Welsh Government Knowledge and Analytical Services reviewed the data in preparation for publication

Revised and updated RTT statistics for Betsi Cadwaladr University Health Board and NHS Wales were published on StatsWales on 13 January 2026. This included official figures up to October 2025 and provisional data for November, bringing Wales and BCUHB data up to date.

Regular RTT reporting resumed in the next scheduled monthly statistical release on 22 January 2026 which included official figures for November and provisional data for December.

The underlying cause of the data issue and weaknesses in local quality assurance and oversight have been addressed by the health board. 

Revised data for April to August 2025 and updated data for September to November 2025 have been provided by the health board. Quality assurance confirms the data are consistent with expected trends based on operational information.

More broadly, and aside from the known data issue, the health board has demonstrated compliance with mandated data standards on completeness and accuracy of RTT reporting. Together with confirmation that the missing pathways are now included, this provides the assurances necessary to reinstate full RTT reporting for Wales.

The impact of data revisions on key measures for Wales and BCUHB are presented below.

For August 2025, total pathways waiting in Wales increased by around 4,784 (0.6%) compared to the original published figure. This includes around 2,560 pathways waiting more than 52 weeks (an increase of 1.6%) and 145 pathways waiting more than 104 weeks (an increase of 1.7%). 

The scale of revisions reduces for earlier months because there was less independent provider activity commissioned in addition to local health board provision. For example, for April there is an increase of 1,148 pathways in total (0.1%), of which 194 were waiting more than 52 weeks and 25 were waiting more than 104 weeks. 

This is consistent with the fact that from August, additional funds were made available to health boards to increase capacity by commissioning activity from independent providers.

For BCUHB the revisions are greater than for Wales as a proportion of the original published figures. 

For August 2025, the revised figures increased by 2.4% total pathways waiting, 4.9% for pathways waiting more than 52 weeks and 2.7% for pathways waiting more than 104 weeks.

The scale of revisions reduces for earlier months. For April 2025, the increases are 0.6% for total pathways waiting; 0.4% for pathways waiting more than 52 weeks and 0.4% for pathways waiting more than 104 weeks.

The review makes recommendations for Betsi Cadwaladr University Health Board to:

• fully embed a strengthened standard operating procedure (SOP) and reconciliation template across reporting cycles including executive oversight and escalation routes
• maintain cumulative validation records, including service-level assurance contributions
• continue structured validation of affected cohorts (EGU, SDEC, trauma) until stable
• introduce quarterly audits of unreported patients and SQL processing logs
• improve mandatory validation comment quality at submission stage
• conduct an internal “post‑implementation review” in early 2026

The review also makes recommendations for NHS Wales and Welsh Government to:

• develop an all‑Wales RTT governance and validation minimum standards framework
• establish a national review of RTT scope with respect to consultant and non-consultant pathways
• strengthen DHCW and KAS trend‑comparison checks, automated alerts and final quality assurance against weekly operational information
• promote adoption of daily or near‑daily internal RTT validation practices
• implement peer‑review audits of RTT datasets between health boards

BCUHB: Betsi Cadwaladr University Health Board
CONSG: Generic code used when the lead clinician for a pathway of care is not yet known
DHCW: Digital Health and Care Wales
EGU: Emergency Gynaecology Unit
HSCEY: Health, Social Care and Early Years Department, Welsh Government
KAS: Welsh Government Knowledge and Analytical Services
NC: Non-consultant code
OSR: Office for Statistics Regulation
PTL: Patient Treatment List
RTT: referral to treatment
SDEC: Same Day Emergency Care
SQL: Structured Query Language
WPAS: Welsh Patient Administration System