51 Acting early on NCDs The Partnership for Health System Sustainability and Resilienceinappropriate utilisation as patients bypass primary care entirely, seeking specialist services directly from hospitals. This fragmentation is particularly evident in the Prolamvano screening programme, where despite providing initial screening services to millions of citizens, there is no formal coordinated pathway for patients with abnormal results to access diagnostic confirmation. Japan operates without standardised criteria for referrals from primary to specialist services, a gap that creates significant variability in practice patterns. Individual providers make ad hoc decisions about when specialist input is needed, based on their own clinical judgement rather than evidence- based protocols. This leads to a dual problem: some providers refer too frequently for expensive diagnostic procedures, contributing to system inefficiency and cost escalation, whilst others delay necessary specialist consultation, potentially missing critical windows for early intervention. The absence of standardised referral criteria means that patient outcomes depend heavily on the individual physician’s experience and risk tolerance rather than systematic, evidence-based pathways. Canada’s fragmented provincial and territorial systems create additional complexity, with each jurisdiction maintaining its own referral processes and criteria (Sussman et al., 2017; Marchildon et al., 2021; PHAC, 2021). The lack of interprovincial coordination means that patients moving between provinces may face repeated diagnostic workups or lost referrals (Marchildon et al., 2021). In addition, 17% of Canadians adults lack a regular healthcare provider, meaning they have no consistent point of entry for diagnostic referrals, often defaulting to walk-in clinics or emergency departments where continuity is absent (CIHI, 2024, Lofters et al., 2023; Weaver et al., 2014). Specialist consultation and assessment Once referred, patients encounter widely varying wait times for specialist consultation that reflect capacity constraints and distributional inequities. Urban-rural disparities in specialist availability contribute to large differences in access, with only about 13% of family physicians and 2% of specialists practicing in rural areas (CIHI, n.d.), leading to prolonged waits for residents outside major centres. Evidence also shows that emergency presentations account for 26–30% of cancer diagnoses in Canada, indicating failures in access to timely and planned diagnostic pathways (Lofters et al., 2019; Brenner et al., 2020). Greece exemplifies these challenges with median stroke- to-CT scan delays of 255 minutes and unmeasured multi-month waits for non-emergency consultations (Korompoki et al., 2024), whilst Poland’s concentration of specialists in Warsaw, Kraków, and Gdańsk leaves rural voivodeships with less than half the specialist density. The financing of specialist consultations creates additional barriers even within universal coverage systems. Greece’s reliance on charitable funding for certain specialist assessments, France’s co- payment requirements outside the ALD scheme, and regional variations in coverage all demonstrate how financial protection gaps compound access challenges. These barriers disproportionately affect populations already facing geographic and socioeconomic disadvantage, with Italy’s evidence that 22% of southern cancer patients travel north for specialist care illustrating how multiple inequities compound throughout the specialist pathway (FAVO, 2024). Onwards referral following specialist assessment Following specialist assessment, patients requiring referral to treatment services face additional administrative and systemic barriers. Fast-track referral systems attempt to expedite onwards pathways for urgent cases, such as Poland’s coordinated-care pathway programme, yet implementation remains inconsistent and coverage incomplete. In Canada, months-long delays can occur between specialist recommendations and treatment initiation, particularly for high-cost cancer therapies, where approval and funding decisions pass through multiple steps and differ by province (Judith Glennie & Associates Ltd., 2023; Marchildon et al., 2021). Provinces have different approaches: some have introduced streamlined pathways, while others require extensive documentation and multiple review stages, prolonging access. The administrative burden of

PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025