2.3 Tertiary prevention: Referral and access to specialist care Following abnormal screening results, patients must navigate referral pathways to reach specialist care. These transitions represent critical junctures where delays can alter disease outcomes, particularly for conditions where treatment effectiveness depends on disease stage. Referral mechanisms vary widely. Spain has positioned primary care as a gatekeeper determining appropriate specialist input, while Greece operates without effective gatekeeping and with insufficient primary care services – only 6% of physicians work in general practice compared to the EU average of 21%.46 Germany combines gatekeeping with guaranteed specialist access within four weeks, though implementation varies by specialty and region. Japan operates without standardized referral criteria, creating variability where outcomes depend heavily on individual physician judgement.Geographical disparities compound access challenges. Rural and remote populations face disadvantages throughout specialist access pathways that transcend health system models. Poland’s specialist concentration in Warsaw, Kraków and Gdańsk leaves rural voivodeships with less than half the specialist density. Greece’s island populations require air or sea travel to reach specialist services, compounding delays in investigation and treatment. Fragmented information systems impede coordination of care. Despite the near-universal adoption of electronic health records (EHR) in some countries, system interoperability remains problematic. Spain has achieved 99% primary care adoption of electronic health records (EHR), yet only eight of 17 autonomous regions can effectively share medical data.47 Italy faces similar fragmentation, forcing patients to carry paper documents among providers despite universal EMR adoption.Current landscape –Establish clear referral criteria with supporting infrastructure: Ensure systematic dissemination and adherence to evidence-based guidelines specifying when specialist referral adds value vs. when primary care management is appropriate. Embed criteria in clinical decision support systems with regular updates and mechanisms to monitor compliance. –Implement target maximum waiting times: Set explicit time frames for specialist consultation following referral, with enforcement mechanisms and consequences for non-compliance. Cover complete pathways from referral to initial specialist assessment, with operational capacity developed to meet standards consistently. –Create unified information systems: Enable information-sharing between primary and specialist care through interoperable electronic systems. This requires not just technical standards but governance frameworks that mandate data-sharing while protecting privacy, enabling specialists to access comprehensive patient histories and primary care to receive timely feedback. –Build monitoring systems tracking complete pathways: Measure total time from initial referral through specialist assessment to treatment initiation, disaggregated by condition, geography and socioeconomic status. Use regular public reporting to drive improvement through transparency while identifying where targeted interventions are most needed. –Address geographical disparities: Develop hub-and-spoke models linking rural primary care to urban specialists, expand telemedicine for consultations not requiring physical examination and deploy mobile specialist services on regular schedules. Provide transport support and accommodation assistance for rural populations facing compound disadvantages.Policy levers Acting Early on Non-Communicable Diseases: A Framework for Health System Transformation 12

Acting Early on Non-Communicable Diseases 2026