GUEST BLOG: Ian Powell – Hidden waiting list exposed; unmet health need unreported

‘Doing God’s work’ is an interesting expression, Usually it refers to performing acts that are virtuous, altruistic, or, in a religious sense, aligned with divine will.

Often it is attributed to doing difficult or unpaid work that directly benefits others or society, and making a profound positive difference in people’s lives.

God’s work evident in exposure of hidden waiting list practice

However, I believe the expression can be adapted to apply to more secular circumstances including exposing, whether unpaid or paid, questionable practices that are contrary to the common good [Disclosure: I am an atheist].

I have no idea whether experienced Stuff journalist Nikki Mac­don­ald is religious or not. But regardless she has done ‘God’s work’ with her thorough exposure of a hidden waiting list that Health New Zealand (Te Whatu Ora) is not reporting.

Her extensive exposure was published in The Post (9 May): Inside the hidden waiting list. What she is exposing is a big part of unmet patient need that is hidden from the public.

Journalist Nikki Macdonald does God’s work exposing unreported hidden patient waiting list

Macdonald’s paywalled article includes examples of the serious harm done to affected hidden patients who are on an unofficial hidden unreported ‘list’ while they wait hoping to get on the official reported waiting list. During this wait their health conditions further deteriorate.

But, as important as this is and as well Macdonald brings these experiences to the fore, this is not the focus of this post.

Ethically scandalous unmet health need

Instead my purpose is something that I would call ethically scandalous. That is, Health New Zealand (Te Whatu Ora) tracks its official tar­gets for hospital specialist assessment and surgery waits; but it does not track those general practitioner referred patients who are declined access to their needed first specialist assessments.

None of this is new to those working in the health system including doctors, nurses, and managers. It is part of why many doctors and others have been advocating for governments to measure the level of unmet patient need.

Retired general surgeon and a founder of the Christchurch charity hospital Phil Bagshaw is a leading campaigner for measuring full patient unmet need

Nikki Mac­don­ald begins her article with a sobering but revealing example of how this situation leads to increasing patient harm. She cites the experience of Porirua general practitioner Bryan Betty.

After three previous rejections and after two years of worsen­ing symp­toms, his fourth sub­mit­ted refer­ral to see an ear, nose and throat specialist, led to his patient finally being accepted.

However, only the fourth referral will appear in published waiting list data. The three earlier rejected referrals won’t be.

How the referral system works

It is important to understand what these referrals are. They occur when GPs assess that a patient’s medical condition requires further investigation from a hospital specialist.

In other words, more specialised diagnosis is required before what treatment (including surgery) if at all, is appropriate. The GP referral is for what is called a ‘First Specialist Assessment’ (FSA). However, acceptance depends on whether the relevant specialist can perform the FSA.

It is claimed that this decision is made on clinical grounds; that is, has the patient met the ‘clinical threshold’ for accessing an FSA.

However, this is misleading because the GP has already assessed that further hospital specialist investigation (FSA) is clinically required.

Rather than determined by a clinical threshold, access to an FSA is determined by a fiscal threshold that itself is determined by the level of workforce shortages.

In turn this depends on whether the Government, through Health New Zealand, sufficiently invests in the necessary workforce capacity to meet this particular unmet patient need.

The scope for a ‘clinical threshold’ is confined to within the limits set by the fiscal threshold.

A Blackadder character Baldrick’s ‘cunning plan’ to hide true waiting list and unmet need appears to have helped advise health policy

A ‘cunning plan’ somewhat more ‘cunning’ than those emanating from the Baldrick character has been devised to make the health target for FSA access less difficult to achieve.

Instead of applying this health target from the GP’s referral for the FSA, its scope is restricted to when the referral meets the FSA’s fiscal (rather than clinical) threshold. It is only then that the target’s clock starts ticking.

A snapshot

Although, regrettably, Health New Zealand does not track GP referral rejections, it is doable. A few former district health boards which, minus their governance boards and decision-making authorities, are now unempowered districts of the national body, did track them and still do.

What would health journalists and the health system do without the Official Information Act

Nikki Mac­don­ald reports, aided and abetted by her Official Information Act inquiry, that they provide a useful snap­shot of unmet need.

In five districts alone (Nel­son Marl­bor­ough, West Coast, Can­ter­bury, South Can­ter­bury and South­ern) there were 66,575 GP referrals declined for FSAs in 2025.

These rejected referrals included more than 6,000 chil­dren who are symp­tomatic of an explo­sion of neuro-devel­op­mental prob­lems that have seen pae­di­at­ric waiting lists double since 2019.

A traumatising experience

Dr Bryan Betty: “dis­tress­ing for patients. And it leaves already stretched GPs try­ing to man­age escal­at­ing pain or prob­lems…”

Nikki Macdonald reports the above-mentioned Dr Betty (also the chair of the national body of Primary Health Organisations, Gen­eral Prac­tice New Zealand) as saying that:

… being told you’re not bad enough to even get onto an assess­ment wait­ing list is dis­tress­ing for patients. And it leaves already stretched GPs try­ing to man­age escal­at­ing pain or prob­lems they don’t have the time, expert­ise, or fund­ing for.

Further, this time in his own words:

It can be really quite trau­mat­ising for the patient, and for fam­ily as well, who may have to end up provid­ing more sup­port. And it can actu­ally be really demand­ing on the GP.

For Dr Betty, the bigger prob­lem is that, as long as those rejec­tions remain untracked, there is no true pic­ture of how many people actu­ally need hospital spe­cial­ist diagnosis. He adds:

That becomes really, really import­ant, because if we don’t know the amount of patients who are not even get­ting to see a spe­cial­ist, then we don’t know the size of what we call unmet need in the com­munity. There­fore, how can we plan ahead in terms of the amount of ser­vices we actu­ally need to deliver care to the country?

[Note: Recently Dr Betty was appointed to the board of Health New Zealand commencing in July. A good decision that will be interesting to observe how it pans out!]

An attempt at transparency

Former health minister Dr Jonathan Coleman called for greater transparency over rejected GP referrals

An interesting revelation by Nikki Macdonald was the recognition in 2016 by then National health minister Jonathan Coleman (himself a general practitioner) of the import­ance of track­ing this hid­den waiting list. Dr Coleman deserves credit for putting his ethics as a GP before politics.

Arguing transparency he announced a National Patient Flow Project to track refer­ral declines, and their reas­ons. However, it was disestablished in 2018 on the purported ground of complexity and then decommissioned in 2025.

Professor Robin Gauld: declined GP referrals increasing; very worrying

This issue has been researched by Professor Robin Gauld at Australia’s Bond University (previously at Otago University). Macdonald quotes him as saying:

It is aston­ish­ing that there’s still no capa­city to col­lect and report data cent­rally.

If you’re not a high enough pri­or­ity, you’ll be rejec­ted and sent back to your GP for ongo­ing man­age­ment, which in our work, we found is often bey­ond the scope of GPs. So it’s actu­ally really wor­ry­ing.

He was able to find that, in 2018, 11.6% of FSAs were declined. By 2022 this proportion had increased to 13.9%.

Chris Hoffman: it’s tough for these most desperate in need

Chris Hoff­man is the national president of the Ortho­paedic Asso­ci­ation. With surgical precision he observes that:

It’s tough … What we’re doing is try­ing to see the people who are most des­per­ate in need, and make those people who can wait con­tinue to wait. And clearly that’s highly frus­trat­ing, if con­tinu­ing to wait means you con­tinue to be in pain, par­tic­u­larly if you’re unable to work, if you’ve got people that are reli­ant upon you, either as a care­giver or a pro­vider of fin­an­cial sup­port. So it puts huge pres­sure on.

Mapua GP Andre Bonny is reported calling for greater clar­ity about what wait­ing lists look like.

He also brings an additional dimension into the discussion – how many patients are not enrolled with a doc­tor, and how many GPs don’t even bother to refer for con­di­tions they know will be rejec­ted. In his words:

The biggest factor for me, is the declines that don’t even get referred, because every­body knows it’s a com­plete waste of time. And there’s no meas­ure on that.

[Disclosure: I may be one of these patients with my knee]

A symptom of a whole health system under strain

Nikki Macdonald does describe commendable innovative process improvement initiatives to help address the issues highlighted by the hidden GP referral waiting list.

Appropriately these initiatives are clinically led by health professionals, which is where sustainable health system improvements primarily come from.

However, it is difficult to expect too much from health professionals suffering from fatigue and burnout due to extensive workforce shortage caused by health system leadership neglect.

Further, these initiatives mitigate rather than solve the problem. This is like somewhat bending the rising curve of unmet health need rather than reversing it.

Dr Ben Hudson sums up well with a concise understatement.

Macdonald includes a timely concise observation from Lyttelton GP Ben Hud­son. It serves as an effective summing up of the hidden unreported list of those denied access to an essential further investigation by a hospital specialist.

Dr Hudson is also the med­ical dir­ector of the Can­ter­bury based Primary Health Organ­isa­tion Pegasus Health and a senior lecturer at Otago University in the Christchurch Clinical School. He is known for his expertise in pain management and risk communication.

He does this summing up by way of an effective understatement when saying that declined refer­rals from general practitioners are “a symp­tom of a whole sys­tem under strain”.

In recognition of this sympton, why not have an official reported health target for general practitioner referrals for further investigation?

While I’m at it, why not also have an official health target for reducing unmet health need.

These would be targets that would be genuinely doing God’s work!