Key Findings:

• Sub-optimal and uneven utilization: Despite nearly nine years of global availability, CAR T-cell therapy reaches only a low share of eligible patients. In 2023, treatment rates ranged from approximately 30% in France to 11% in Italy in a study across selected European countries.
• System-level barriers: Variation reflects differences in health system readiness. Barriers include fragmented referral pathways, capacity constraints, reimbursement delays, and regional inequities.
• Role of government: Governments are uniquely positioned to address these barriers through coordinated policy frameworks co-developed with clinical societies, hospital associations, HTA bodies, patient advocacy groups, and industry. These frameworks span six interdependent dimensions of health system readiness.
• Governance and strategic planning: Without coordinated national strategies, CAR T delivery can evolve in a fragmented manner, resulting in inconsistent access across the care pathway. National or regional CAR T strategies can define eligibility criteria, center designation, and referral coordination, with regular revision cycles. An example can be seen in Spain, which has Europe's most operationally detailed CAR T delivery framework. Since 2018, Spain has monitored treatment requests by indication, territorial coverage across referring hospitals, Expert Group response times, and the designated center network. Spain continues to refine the plan based on this tracking. For example, gaps in territorial coverage led to successive expansions of the center network, and the 2025–2028 plan extends the model to all advanced therapies.
• Financing and payment innovation: DRG-based reimbursement rarely captures the non-therapy costs of CAR T delivery completely, so hospitals can be forced to absorb these costs, while patients can face out-of-pocket travel and accommodation expenses. Reimbursement models may need to assess the full care pathway and associated costs, not only for the therapy itself, and government-backed patient assistance programs may be needed address travel and accommodation costs when applicable. Some best practices have been observed in France, where the liste en sus adds funding for the innovative drug on top of DRG tariffs so that hospitals are not financially penalized for delivering CAR T. Australia's government-funded Patient Assisted Travel Schemes cover travel and accommodation for patients and caregivers.
• Facility readiness and need for shared-care models: Many CAR T centers are operating at or near capacity, with limited ICU beds and apheresis capacity creating bottlenecks as demand grows. Shared-care and outpatient models can extend capacity without compromising outcomes, supported by national reporting on center capacity and patient throughput. An example can be seen in France, where Toulouse University Hospital moved pre-CAR T lymphodepletion to referring centers and cut median hospital stays from 20 to 14 days.
• Workforce development and expertise: Shortages exist across most CAR T roles, nurses remain underutilized, and administrative burden frequently diverts physician time from patient care. Accredited training, expanded nurse roles, and dedicated care coordinators can ease these constraints. Some best practices have been observed in the UK, where the ATTC Network provides an NHS readiness toolkit with more than 64 training resources for healthcare professionals. In addition, non-medical prescribing guidance enables qualified nurses and pharmacists to prescribe subsequent cycles of systemic anti-cancer therapy. While these steps my not be focused on CAR T directly, they suggest directions that can be explored.
• Patient referral pathways: The CAR T journey spans multiple institutions, and fragmented communication and inconsistent referral practices can delay treatment or prevent eligible patients from reaching it. Standardized, disease-specific referral tools, maximum referral-to-treatment timelines, and publicly reported KPIs can promote timely and equitable access. Some best practices have been observed in Spain, where the IDEaL initiative (2024) turned national strategy into disease-specific referral guidance. In Australia, weekly national prioritization meetings direct patients from any region to an available treatment slot.
• Data infrastructure and outcomes monitoring: Current data systems rarely capture the full patient journey, including referral delays and eligible patients who are never treated, which limits the ability to identify access gaps. Interoperable national registries that capture the full patient pathway can serve as a foundational investment. An example can be seen in France, where the DESCAR-T registry has enrolled 5,000 patients across 36 centers and tracks eligible patients who did not receive therapy. Its data has informed changes in clinical practice and reimbursement decisions.