PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

50 Acting early on NCDs The Partnership for Health System Sustainability and Resilience 4 Tertiary prevention: Referral and access to specialist care Following abnormal screening results, initial clinical suspicion, or the need for specialist expertise, patients must navigate complex pathways through health systems to reach appropriate specialist care. These transitions, from primary care to specialist services, between different specialists, and back to primary care, each represent potential delays that can alter disease outcomes. Significant inefficiencies are caused by duplication of tests and poor handover of care between different specialists and primary care. For NCDs, where treatment effectiveness often depends on disease stage and timely intervention, the cumulative impact of pathway delays can transform manageable conditions into advanced disease. This chapter examines how health systems organise referral and access to specialist care for NCDs, recognising that not all conditions require specialist involvement. As discussed in Chapter 3, many NCDs can be effectively diagnosed and managed in primary care when appropriate resources and authority exist. This chapter focuses on situations where specialist input becomes necessary: for complex diagnosis, for treatment planning requiring specialist expertise, or for initial specialist assessment. It analyses referral mechanisms, waiting times for specialist consultation, coordination between providers, and the persistent challenge of ensuring continuity across separate services. The specialist referral pathway Initial referral to specialist services The first critical transition, either from primary care to specialist services or direct presentation to a specialist, reveals important differences in health system organisation and their consequences for patient care. Countries demonstrate markedly different approaches to managing this initial contact, with important implications for both efficiency and equity. Spain has positioned primary care as the foundation of its health system, with general practitioners serving as gatekeepers who determine when specialist input is needed. This system emphasises continuous coordination with specialised care through shared protocols and communication systems. The country has invested in strengthening this coordinating role, with primary care physicians managing initial investigations and determining appropriate referral timing. However, the effectiveness varies significantly by region, with wealthier autonomous communities such as Madrid and Catalonia maintaining more robust primary care infrastructure than regions like Extremadura or Andalusia (Instituto Nacional de Estadística, 2021). Germany’s approach combines gatekeeping with guaranteed access. The appointment scheduling system, operated by the Association of Statutory Health Insurance Physicians, requires that patients with referrals for diagnostic procedures are allocated specialist consultation within four weeks. This represents a structural attempt to address access delays through mandated timeframes. However, the system faces challenges in implementation, with significant variations in actual waiting times depending on specialty and region, and the four-week guarantee applying only to initial consultation rather than actual diagnostic procedures. Moreover, many patients continue to bypass primary care completely and directly present to specialists. In contrast, Greece’s healthcare system operates without effective gatekeeping mechanisms and the report documents insufficient primary care services, with only 6% of physicians working in general practice compared to the EU average of 21%. Hospital emergency departments struggle with