PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

5 Acting early on NCDs The Partnership for Health System Sustainability and ResilienceRECOMMENDATIONS: ■ Establish clear referral criteria with supporting infrastructure: Develop evidence-based guidelines specifying when specialist referral adds value versus when primary care management is appropriate. Embed these criteria in clinical decision support systems with regular updates based on emerging evidence. Critically, ensure primary care has the resources and authority to manage conditions within their scope, avoiding unnecessary referrals that fragment care. ■ Implement target maximum waiting times for specialist access: Set explicit timeframes for specialist consultation following referral, with enforcement mechanisms and consequences for non- compliance. These targets must cover the complete pathway from referral to initial specialist assessment, with operational capacity developed to meet standards consistently rather than creating aspirational targets without delivery capability. ■ Create unified information systems for seamless coordination : Enable information sharing between primary and specialist care through interoperable electronic systems, eliminating the current reality where patients carry paper documents between providers. This requires not just technical standards but governance frameworks that mandate data sharing whilst protecting privacy, enabling specialists to access comprehensive patient histories and primary care to receive timely feedback. ■ Address geographic disparities in specialist access: 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 who face compound disadvantages at every stage of the referral pathway. ■ Build monitoring systems that track complete pathways: Measure not just individual waiting times but total time from initial referral through specialist assessment to treatment initiation, disaggregated by condition, geography, and socioeconomic status. Use regular public reporting of pathway performance to drive improvement through transparency whilst identifying where targeted interventions are most needed. Tertiary prevention: Treatment & disease management CURRENT LANDSCAPE: Successful models demonstrate potential: Germany’s Disease Management Programmes (DMPs) provide structured care to millions with documented improvements in outcomes, while Italy’s new DM77 reform establishes community health centres as integrated care hubs. Yet challenges persist. Disease-management programmes often remain disease-specific and administratively heavy. Despite 68.1% of Italian citizens aged 65+ receiving prescriptions for at least five different substances, no country has developed comprehensive guidelines for multimorbidity management. High rates of avoidable hospitalisation in some settings indicate gaps in coordination, while the pandemic revealed extreme vulnerability of NCD services to disruption. RECOMMENDATIONS: ■Develop guidelines for multimorbidity with practical decision support: Move beyond single- disease guidelines to address common disease combinations explicitly, providing frameworks for prioritising interventions when recommendations conflict and protocols for deprescribing when risks exceed benefits. Clinical decision support tools should help reconcile competing guidelines whilst maintaining focus on what matters most to individual patients rather than disease-specific targets.