Growth in rejected referrals hitting hard

A GP will only make a referral when it is warranted; these patients have a genuine clinical need for specialist healthcare – and they are not getting it

Understanding all the factors impacting the practice team is crucial for addressing the increasing pressures general practice faces.

The idea to investigate unmet need arose when the Planned Care Taskforce was established to “reset and restore” planned care. At the time, General Practice NZ pulled together a working group to write a proposal addressing the taskforce report’s primary care elements. In doing so, unmet need quickly became a discussion point.

This was not in the taskforce’s remit, but the working group had enough anecdotal information to determine it was a system issue that warranted further insight.

From here, GPNZ commissioned the University of Otago Centre for Health Systems and Technology (CHeST) team to research the topic. The final report, Quantifying and understanding the impact of unmet need on New Zealand general practice, was released in June.

The research was designed to gain a solid understanding of the occurrence of unmet need, its impact on practices, and how it is being responded to. This meant requesting data from Te Whatu Ora as well as gathering in-depth insights from practice teams on how they respond and manage unmet needs.

The researchers carried out six detailed site visits to a deliberately selected range of practices covering mainstream, kaupapa Māori, urban and rural areas. GPNZ stayed close to the research team, helping to build a strong relationship with Te Whatu Ora to support a large, complex data request and to make introductions to the practice case study sites, facilitating good access for the researchers to the practice.

So, what did we find? While GP referrals remained fairly static at about 600,000 per year between 2018 and 2022, access to referred specialist services declined notably, with rejected referrals climbing from about 63,000 to 85,000 – with predictions this will continue to grow.

In subsequent media interviews following the release of the research, I have been at pains to explain a GP will only make a referral when it is warranted; these patients have a genuine clinical need for specialist healthcare – and they are not getting it. This leaves GPs managing complex cases without extra resources or support.

The study shows the impact on patients, who are experiencing increased costs and likely poorer outcomes, but also an enormous burden placed on practice staff, including increasing stress and burnout for GPs and financial impacts to their practices. Direct quotes from study participants are given throughout the report, making for very sober reading, and providing richness to the story the data presents.

So, now we’ve uncovered these findings, where to next? GPNZ has supplied a copy of the research to the Government, opposition parties and key stakeholders in the health system. We’ve secured multiple follow-up meetings to discuss the findings and begin to look at management and solutions.

One clear outcome we seek is for this previously invisible problem to become routinely measured. We are getting more visibility of first specialist assessments and surgical wait lists, enabling targets to be set against them. Let’s get that same level of visibility for those who should be on the waitlist and never get there.

We’d also like to see some rigour placed around surgical waiting lists, ensuring people who have been assessed by the surgeon and meet criteria are not removed from the list and referred back to practice.

Until we operate with this level of transparency, we can never fully understand the health of our population and respond accordingly. Beyond transparency, we need to work on a range of approaches to address and relieve the pressures on practices to support patients with unmet needs. This is another key piece in assuring general practice sustainability.

Bryan Betty is chair of General Practice NZ and a specialist GP in Porirua