28 May 2020
Amy Van Dey Lovatt
Email: [FYI request #12108 email]
Dear Ms Van Dey Lovatt
Official Information Act (1982) Request
I write in response to your Official Information Act request, received by us on 04 May 2020, via
partial transfer from the Ministry of Health under section 14 of the Act. You noted the fol owing
and requested information on inter-district flow and referrals.
I am a New Zealand citizen. Waikato DHB, my DHB of Domicile (DoD), has insisted that my
GP provide a referral to services outside my DoD; however, when my GP referred me to the
Southern DHB, the only DHB we could find which had a protocol consistent with the
Endocrine Societies Guidelines for testing for hyper-aldosteronism, the Southern DHB
rejected the referral, on the grounds that the referral was from my GP and not my specialist,
Dr Wu, at my DoD. Clearly, Waikato DHB and Southern DHB cannot both be correct, as they
contradict each other. [The statement, referrals must be from GPs AND referrals cannot be
from GPs, is logically false.]
The MoH Operational Policy Framework 2019/20, available through Nationwide Service
Framework Library <https://nsfl.health.govt.nz>, states under section 7.5.2 "Regions should
ensure that clear referral pathways are in place and known to al clinicians." Given that
every DHB must "ensure that clear referral pathways are in place and known to all
clinicians", clearly such policies must exist, and thus section 18(g) cannot apply to my
Request 1: Thus, I request, under section 13 and 14 of the OIA that you please assist me in
obtaining these policies, even if it requires transferring my request to each and every DHB
or another relevant agency, which would have the required information.
As context, Counties Manukau Health (CM Health) provides and funds health and support services
to people living in the Counties Manukau region (approx. 569,400 people). Our services are
delivered via hospital, outpatient/ ambulatory and community-based models of care.
We also provide some regional and supra-regional specialist services (for orthopaedics, plastics,
burns and spinal services). There are specialist services provided for our community under regional
agreements via other metro-Auckland DHBs, including many tertiary surgical/ medical services,
Counties Manukau District Health Board
Private Bag 93311, Otahuhu, Auckland
T: 09 276 0000 | cmdhb.org.nz
some mental health and addiction services, and specialist child health services. In addition, many
services are provided in our communities by contracted providers, including primary care,
midwifery, community support and age-related residential care facilities.
Our response to your request for referral pathway information/ polices is as fol ows
New Zealand DHB’s are funded by the government to provide health and disability services to their
resident populations – using a population based funding formula (PBFF). Broadly, the arrangements
for elective service referral pathways begin from the point a person is referred by their primary
care provider to specialised care within their region.
There are some specific exceptions for the PBFF funding arrangements for specialist regional and
national services (e.g. Spinal injury, Neurosurgery and transplant services). The Ministry of Health
defines overal policy and specifications via the Nationwide Service Framework Library repository,
including the Crown Funding Agreement Schedules, Operational Policy Framework and Service
In particular, where a DHB does not directly deliver a service, it can negotiate with another DHB to
provide some services via an Inter-district Flow (IDF) arrangement (for example, CM Health has an
arrangement with Auckland DHB to provide Cardiothoracic and Neurosurgery to our population).
As a part of each annual planning cycle, the Ministry of Health provides DHBs with suggested
annual IDF volumes by speciality. These IDF arrangements are negotiated each year, the volumes
can be adjusted and cases are funded for by the DHB of domicile via a national y agreed funding
The Ministry of Health provides the Operational Policy Framework 2019/20
, which you refer to in
your request, as the basis on which DHBs manage these situations, and includes ful guidance on
the processes [section 7 – Inter-district Flow]. We apply these policies to the referral management
process with our district.
In addition to the section of the Operational Policy Framework which you refer to, the document
includes a statement that “where a DHB of domicile provides a speciality, any referral of elective
cases to another DHB would only be in exceptional circumstances, and should be via a Specialist to
When CM Health receives an IDF referral for a patient from outside our district, and outside of
existing arrangements described above, we do expect it to come from a Specialist in the domicile
DHB, and we need to gain funding approval from that DHB, as it will pay for services provided.
Receiving DHBs must also consider their capability and capacity to provide the requested service,
for both their community and any other cases, and can determine whether to accept a referral or
not. Inter-district referral is not an entitlement for services.
The northern region (Auckland, Northland, Waitemata and Counties Manukau DHBs) maintain a
system of clinical referral pathways tools for Primary Care providers across many clinical specialities
and diagnoses. These pathways are to support primary care practice, particularly for the clinical
management of common conditions seen in primary care, and supply advice for practitioners using
consistent guidance on when to refer for a Specialist opinion.
These pathways are accessible to clinicians via:
With regard to specialist Endocrinology Services – while we cannot speak to the particulars of your
experience, CM Health does not have an IDF arrangement to provide/ access to this specialist
service via other DHBs. General Practitioners in our region are guided to refer patients to the DHB
of domicile of the patient.
I trust this information satisfactorily answers your query. If you are not satisfied with this response
you are entitled to seek a review of the response by the Ombudsman under section 28(3) of the
Official Information Act.
Please note that this response or an edited version of this may be published on the Counties
Manukau DHB website.
Fepulea’i Margie Apa
Chief Executive Officer
Counties Manukau Health