Beyond prescribing rights: designing equitable and sustainable attention-deficit/hyperactivity disorder care pathways in Aotearoa New Zealand

From 1 February 2026, vocationally trained general practitioners (GPs) and nurse practitioners (NPs) in Aotearoa New Zealand are authorised by Medsafe and Pharmac to initiate stimulant medication for the treatment of adult attention-deficit/hyperactivity disorder (ADHD) (≥18 years).¹ This change represents a substantial departure from the previous model in which stimulant initiation was largely limited to vocationally registered psychiatrists and paediatricians but with local variations that include psychologist input to diagnosis. This change reflects recognition of long-standing inadequacies and inequities in treatment pathways. Prior to the changes, Aotearoa New Zealand’s model for the initiation of stimulant medication for the treatment of adult ADHD aligned with that of Australia, the United Kingdom and Ireland.^2–4 These changes make Aotearoa New Zealand’s model align more closely with that of the United States of America and Canada.^5,6 Australia is gradually introducing reforms to stimulant prescribing state by state that will allow for a greater role of primary care in ADHD.⁷

The adverse impacts that ADHD can have across multiple domains of life that include education, mental health, substance abuse and the judicial system are well known.⁸ Evidence of effectiveness of treatment is clear with significantly improved social outcomes in multiple areas such as all-cause mortality, self-harm, crime and unintentional injury.⁹ Research suggests that a considerable proportion of individuals in Aotearoa New Zealand who may benefit from ADHD medication do not currently receive treatment.¹⁰ While expanded prescribing authority addresses one structural barrier, other constraints such as cost, long wait times and limited specialist availability are likely to persist. Overseas research reveals that inequities in ADHD assessment and care occur across socio-economic status, ethnicity, rurality, gender diversity, and co-existing neurodevelopmental or mental health conditions.¹¹ Some individuals experience multiple minority statuses, including gender, race, class, ethnicity, disability, addiction and co-existing mental health problems, resulting in compounding disadvantage in access to ADHD assessment and treatment.¹² Further, Māori and Pacific people appear to be particularly disadvantaged by health inequities in ADHD treatment pathways.¹³

During national consultation by Medsafe and Pharmac about prescribing changes, individuals with lived experience described difficulty accessing diagnosis and treatment, often citing delays of months to years and high costs for private assessment.¹⁴ The report also found that medical practitioners and nurses emphasised concerns relating to diagnostic complexity, insufficient training, limited consultation time, risks of inappropriate prescribing and perceived pressure to prescribe stimulants.

Although expanding prescriber eligibility is intended to reduce bottlenecks, increase accessibility and balance workload across the system, there remains limited discussion of the practical requirements for safe and accurate diagnosis, nor discussion of how clinical pathways should be designed to ensure equitable access for marginalised populations. There is also the recognised need for professional development and interprofessional collaboration to facilitate a more consistent model of service.¹⁵ While other considerations such as risk of medication misuse or diversion are important, this article focusses on structural and systemic factors most relevant to sustainable and equitable service delivery; equity, diagnostic quality and service sustainability.

Results

The New Zealand Clinical Principles Framework for Attention Deficit Hyperactivity Disorder jointly developed in 2025 by the Ministry of Health – Manatū Hauora, Pharmac and the Royal New Zealand College of General Practitioners (RNZCGP) provides high-level guidance for diagnosis and management.¹⁶ However, the framework lacks operational detail, and several issues remain unresolved. Recommendations that clinicians possess “expertise” in ADHD assessment or be supervised by an experienced clinician are not supported by mandatory training requirements, competency standards or quality assurance mechanisms. Further, reference to “validated diagnostic tools” is not accompanied by guidance regarding which instruments should be used, how they have been validated and in what populations, how clinicians should be trained to administer them or what constitutes adequate assessment.

A further challenge for diagnosing ADHD is that more than 60% of adults with ADHD present with at least one comorbid psychiatric or neurodevelopmental condition, including anxiety disorders, depression, post-traumatic stress disorder (PTSD), autism spectrum disorder and personality disorders.¹⁷ Many of these conditions mimic, mask or coexist with ADHD, posing a risk of misdiagnosis in the absence of comprehensive assessment.

An assessment framework relevant to Aotearoa New Zealand, drawing on overseas guidelines, offers structures that may be applicable to primary care.¹⁸ The framework suggests that the assessment process should encompass:

• Diagnosis by a registered and appropriately trained practitioner
• Incorporation of developmental, mental and physical history
• Use of observer reports from school and/or family where available
• Adherence to Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) diagnostic criteria
• Consideration of alternative explanations for presenting symptoms
• Evidence of impairment across multiple settings (e.g., home, work, leisure)

Detailed processes for diagnosis and treatment are available from overseas jurisdictions. The Adult ADHD Assessment Quality Assurance Standard (AQAS), developed in the United Kingdom, provides a practical resource to support reliable and valid diagnostic assessments of adult ADHD and is available in the public domain.¹⁹ Australian guidelines cover identification, screening, diagnosis, multimodal treatment and support, including pharmacological and non-pharmacological interventions.²⁰ Prescribing guidelines are available from Australia, the United Kingdom and Canada.^21–23  One purpose of detailed guidelines is to improve assessment accuracy and avoid misdiagnosis or under-diagnosis. Failure to recognise comorbidities such as PTSD may lead to inappropriate prescribing, inadequate monitoring, or insufficient provision of non-pharmacological interventions, particularly in diagnostically complex populations. Imported guidelines, while informative, do not adequately reflect specific nuances of Aotearoa New Zealand, in particular, Te Ao Māori, and are not underpinned by Te Tiriti o Waitangi.²⁴

Equity considerations

While expanded prescriber authority may reduce structural barriers such as cost and geography, equity is not automatically improved. Historically, racial bias, cultural unsafety and discrimination towards marginalised communities, including Māori, Pacific people and LGBTQIA+ communities, have contributed to inequities in ADHD care.^25–27 This may persist irrespective of increased prescriber numbers. Inaccurate but persistently held views (such as ADHD being found overwhelmingly in males) may also affect equity issues. Without explicit safeguards, inequities in referral pathways, quality of assessment and timeliness of care may remain, or worsen, particularly for Māori, Pacific and those living in rural regions. Inequitable pathways risk not only delayed access, but also differential diagnostic accuracy and treatment quality across population groups.

Service delivery implications

A comprehensive ADHD diagnostic assessment typically requires 1–3 hours, depending on clinical complexity.²⁸ Such time requirements pose challenges for a primary care system already experiencing significant workforce pressure. Internationally, GPs report low levels of confidence in their ability to diagnose and prescribe for ADHD, and it is likely that GPs and NPs in Aotearoa New Zealand feel the same. While medication is considered the most efficacious treatment, other therapies are available. Cognitive behavioural therapy, psychoeducation and advice on lifestyle modifications are available, but resourcing these services has historically proved difficult and commonly cost-prohibitive.²⁹ Psychologists occupy a distinct role in ADHD care, with the potential to contribute to both diagnosis and therapy. Their involvement in service delivery may become increasingly prominent, particularly in models where elements of assessment and therapy are distributed across professional groups.

Several models of ADHD care are likely to emerge as primary health organisations (PHOs) and practices adjust to the changes:

1. Primary care–led model: GPs/NPs undertake the full assessment, diagnosis and treatment process. This is unlikely to reduce cost barriers to assessment in a meaningful way.
2. Shared-care/interprofessional model: Independent mental health nurses, psychologists or occupational therapists conduct assessments; GPs/NPs oversee medication management. Having allied health professionals undertake components of assessment may alter the cost structure of care, although the overall impact on patient cost is uncertain and likely to vary by model.
3. Specialist diagnosis model: Practices continue to refer routinely to private psychiatrists or paediatricians for diagnosis, with GPs/NPs managing treatment thereafter. This will result in no improvement from the current position.
4. PHO–led diagnostic services: PHOs provide dedicated ADHD assessment services, enabling economies of scale. Prescribing and psychoeducation remain with GPs/NPs. This also represents a model with the potential to reduce cost barriers.
5. Practice-embedded mental health clinicians: Individual practices employ mental health nurses or allied health clinicians for in-house assessment. Prescribing and psychoeducation remain with GPs/NPs.
6. Private ADHD clinics: Commercial clinics provide assessment, diagnosis, initiation of medication, and non-pharmacological interventions. This pathway has been criticised for overdiagnosis of ADHD if poorly regulated.

Each model has distinct implications for cost, accessibility, workforce sustainability and service consistency. Each PHO, practice and practitioner will adapt to the changes according to circumstance that includes workforce, knowledge of ADHD and commitment to the intent of policy change.

Discussion

At present, no Aotearoa New Zealand data exist on primary care–initiated stimulant prescribing for adults, underscoring the importance of early policy evaluation following implementation. The changes in stimulant prescribing present both opportunities and challenges. On one hand, authorising GPs and NPs to initiate stimulant treatment has the potential to reduce delays, improve access and create more equitable care pathways for individuals with ADHD. On the other, the absence of detailed operational guidance risks inconsistent assessment quality and variable capacity across regions, risking “postcode lottery” outcomes. International evidence underscores the importance of structured diagnostic pathways, validated assessment tools and interprofessional collaboration. Jurisdictions such as the United Kingdom commonly incorporate shared-care arrangements, specialist input for complex cases and clearly defined training and competency standards, elements that are not currently present in Aotearoa New Zealand’s implementation plan.

An additional consideration is the risk of stimulant misuse and diversion. Expanded access to prescribing may increase demand for assessment and treatment, including from individuals seeking medication for non-therapeutic purposes. International experience suggests that while most prescribing is appropriate, systems without clear diagnostic standards, monitoring processes and clinician support may be vulnerable to inappropriate prescribing. Addressing this risk requires balanced approaches that include clinician training, clear prescribing guidance, and monitoring frameworks, while avoiding policies that inadvertently restrict access for those with genuine clinical need.

Although patients already bear significant costs, particularly for private psychological and psychiatric services, without a clear equity focus, new models risk perpetuating or even exacerbating these costs. Lower-cost models may achieve affordability through shorter, less comprehensive assessments or by relying on less experienced assessors, potentially at the expense of diagnostic quality, access to multimodal treatments and appropriate prescribing. The transition of ADHD diagnosis and initiation into primary care will increase demand for longer appointments, follow-up reviews, cardiovascular monitoring and ongoing medication management. This may divert GP workforce capacity away from generalist care, compounding existing pressures in primary care and rural services.

ADHD assessment in adults is inherently complex, given high rates of psychiatric comorbidity and overlapping symptomatology with other conditions. Without sufficient training and oversight, clinicians may be placed in ethically challenging positions, balancing patient expectations, time pressure and diagnostic uncertainty. PHOs and practices will require strategic planning, including decisions regarding pathway design, workforce development, cultural safety and funding models. Failure to address these issues could lead to unintended consequences, including widening inequities and clinician burnout.

Conclusion

The expansion of prescriber authority for ADHD medications represents a significant policy shift aimed at addressing long-standing access barriers in Aotearoa New Zealand. Implementation of policy now becomes a crucial factor. Achieving equitable and high-quality ADHD care will depend on robust training, clear clinical standards, well-designed pathways and adequate resourcing of primary care services. As practices and PHOs negotiate the new ADHD landscape, they need to place equity of outcome as the priority outcome of change. The easy path is to use a model that is convenient to the practice and practitioners. Without explicit equity-focussed pathway design, expanded prescribing authority risks reproducing existing inequities through variable assessment quality, differential access to multidisciplinary input and uneven cost shifting. A co-ordinated national approach, supported by PHOs, professional colleges and policymakers, is essential for delivering safe, effective, equitable and culturally grounded ADHD assessment and treatment.