In all OECD countries and beyond, healthcare systems are under unprecedented pressure to strengthen their resilience. This follows the dramatic impact of the COVID‑19 pandemic, and the need to address new demands coming from the demographic transition and technological change. To effectively respond to this pressure, policy makers need the best possible array of information and data. Much progress has already been made through harmonised OECD statistics to collect granular information on health spending and financing, on outcomes based on conventional metrics, such as mortality and morbidity rates, on clinical quality and safety of care, and on inputs such as number of doctors, nurses, hospital beds and other resources available.
Does Healthcare Deliver?
Results from the Patient-Reported Indicator Surveys (PaRIS)
Yet, an essential piece of information is still lacking: the views of those directly concerned by health services – the patients – regarding their experiences with the healthcare system and the outcomes they reported. The OECD Patient Reported Indicator Surveys (PaRIS) addresses this knowledge gap by assessing not only whether patients survive but also whether they thrive. Unlike disease‑specific assessments, PaRIS adopts a broader approach, evaluating how healthcare affects patients’ lives across multiple dimensions. This comprehensive perspective has the potential to revolutionise the way we assess the performance of healthcare systems globally.
PaRIS is the first international survey to provide harmonised indicators on the healthcare experiences and health outcomes of people aged 45 years and older living with chronic conditions, particularly within the context of primary care. The survey echoes the voices of around 107 000 patients in more than 1 800 primary care practices in 19 countries (Australia, Belgium, Canada, Czechia, France, Greece, Iceland, Italy, Luxembourg, Netherlands, Norway, Portugal, Romania, Saudi Arabia, Slovenia, Spain, Switzerland, Wales (United Kingdom) and the United States), representing nearly 104 million primary care users. The survey focuses on people aged 45 years and older as this group is growing in number but also in the complexity of their care needs.
Addressing these needs effectively requires changing the ways the healthcare system works; moving away from an episodic, curative approach focused on “addressing specific health concerns” towards a healthcare model that puts the “whole person” at the centre and that is organised around the needs of people.
PaRIS gives patients a voice. It captures what matters to them, including their physical functioning, social functioning and psychological well-being, putting together ten key indicators that summarise the primary care experiences and health outcomes of patients in the surveyed countries. The ten indicators include five Patient-Reported Experience Measures (PREMs). PREMs measure patients’ experiences with the healthcare they receive, including their confidence to self-manage health conditions, co‑ordination of care, person-centred care, experienced quality of care, and trust in healthcare. The five other key indicators are Patient-Reported Outcome Measures (PROMs). PROMs capture patients’ assessment of their health and symptoms, in this case physical health, mental health, social functioning, well-being, and general health.
Life expectancy at birth has increased by more than ten years across OECD countries since 1970, which has gone hand in hand with an increase in the number of people living with chronic conditions and higher healthcare costs. PaRIS finds that around 8 out of 10 people aged 45 years and older who had a primary care consultation in the previous six months have at least one chronic condition. More than half have two or more conditions, and more than a quarter even three or more. This takes a large toll on people’s lives. PaRIS results show that the average WHO‑5 well-being score (a scale from 0 to 100) was five points lower among people with two chronic conditions and 14 points lower among people with three or more chronic conditions compared to people with one chronic condition.
The PaRIS results allow for far deeper understanding of what matters to patients, enabling them to live longer, better and healthier lives. It highlights a clear relationship between patients’ experiences of primary healthcare and their self-reported physical, mental and social health, known as health outcomes. For example, PaRIS results show that in Switzerland and among the United States population aged 65 years and older enrolled in Medicare, most people consistently report positive care experiences and better health results compared to the OECD average. In Australia, Czechia, France and Norway, most people also report positive experiences with their care, along with relatively good health outcomes. There are countries that do well either on outcomes or in experience of care, but not at both, including Greece, Iceland, Italy, Portugal, Romania and Spain. Wales (United Kingdom) and Portugal display relatively poor outcomes and experiences of care. However, even in the countries with the best performance there are large variations in experiences and outcomes across different socio‑economic groups.
PaRIS showed positive relations between health spending in a country and measures such as good physical health, well‑being, and experienced quality of care. However, these correlations are not strong, except for physical health. This indicates that while higher health spending may be associated with better outcomes for some indicators, it does not guarantee improved patient outcomes or experiences across the board. Notably, it is possible to achieve comparatively strong performance at lower levels of health spending. Czechia and Slovenia, for example, both score well across most of the PaRIS indicators, while having relatively low health spending per capita. While the United States reports favourable scores on experienced quality and well-being, it spends more than double the amount per capita of some other countries with comparable scores.
Greater availability of health workforce is positively associated with three of the ten PaRIS key indicators. For example, in countries with larger health workforces, such as Iceland, Norway and Switzerland, the average level of well-being is higher. Similar patterns emerge for physical health and mental health scores. While this analysis does not establish causality, it highlights the potential benefits of investing in healthcare staffing to improve patient-reported health outcomes.
Across all countries in the survey, there are significant gender gaps in the experiences and outcomes of patients. On average, women’s well-being scores are typically 3% to 5% lower than men’s. The gender gap is as high as 9% in some countries, such as Portugal and Italy, two countries with relatively low overall performance, and smaller than 3% in Luxembourg and the United States with relatively good performance. Socio‑economic status, age, and living with multiple chronic conditions explain part of the difference, but even when these factors are considered, the report shows that women’s well-being is still worse than men’s.
Disadvantaged people with low levels of education and income face a double disadvantage: they fall ill and develop more chronic diseases earlier in life, and, once sick, they experience worse health outcomes compared to those with chronic conditions but who are better off in terms of education or income. Of patients between 45 and 54 years of age, 34% of higher-educated people have no chronic conditions, compared to only 23% among those with the lowest education levels. There are also significant differences in mental and physical health scores between the highest and lowest education and income groups, ranging from less than 2 to more than 7 points across education groups, and from about 2 to over 5 points across income groups (PROMIS® Scale v1.2 – Global Health components for physical and mental health: 10 points corresponds with approximately one standard deviation difference). Such disparities persist even after accounting for age and the number of chronic conditions, but country averages mask inequalities within countries. For example, both Canada and the United States have above‑average mental health scores compared to other countries. However, while Canada has the smallest gap in mental health scores across education groups (1.6 points difference), the United States has the largest gap (7.8 points difference).
Managing multiple chronic conditions is far more complex and costly than managing a single condition. This is particularly important as PaRIS shows that, among the people who live with multiple chronic conditions, over 70% take at least three medications, and more than a third take four or more medications.
In addition to the number of conditions, their specific combination has important consequences for healthcare experiences and outcomes. Sixteen percent of the patients with chronic conditions in the survey live with at least one mental health condition. PaRIS shows that people with multiple chronic conditions report worse physical health and social functioning and are less confident that they can manage their own health when one of their conditions is a mental health condition.
1. Patients value Time: Shorter waiting times and more time with primary care professionals are highly valued by patients. People who reported that their primary care professional spent enough time with them are almost 90% more likely to trust the healthcare system compared to those who did not perceive this was the case (64% compared to 34%). Patients who experience waiting times that they consider problematic are also less likely to trust the healthcare system, this pattern was consistent in all PaRIS countries. People with multiple chronic conditions who have longer time with primary care professionals are more likely to report better quality of care.
Results also show that continuous relationships matter to patients. Patients with a long-standing relationship with their primary care professional report better care experiences. The highest proportions of patients with such long-term continuity were observed in two of the countries with relatively good overall performance, Czechia and the Netherlands, but also in Romania. In these countries, over half of patients indicated being with the same primary care professional for more than a decade.
2. Patients need personally Tailored care: In managing care for people with (multiple) chronic conditions there is usually no “one‑size‑fits-all” solution. PaRIS results demonstrate that care becomes better tailored to people’s needs when healthcare professionals explain things clearly and provide written instructions to help patients manage their care at home.
Although most people with chronic conditions regularly consult healthcare professionals, they live with their conditions 24/7, requiring continuous self-management within their own environments. This highlights the importance of tailoring care to individual needs and equipping patients with the knowledge and skills necessary to manage their own health and well-being effectively.
People are significantly more confident in managing their health when doctors involve them in decisions and when they receive strong self-management support, with confidence levels highest in France and the Netherlands. Regular medication reviews and care plans enhance care co‑ordination. While 85% of patients in some countries report having medication reviews, the use of care plans is much lower, averaging just 25% among patients with chronic conditions. In some countries, like Australia and Romania this exceeds one‑third, but it falls below 10% in others, like Netherlands and Wales.
3. Patients need Trouble‑free and safe care: People who have experienced an event or circumstance that could potentially cause them harm in healthcare – such as, not getting an appointment when needed, receiving a wrong or delayed diagnosis or treatment, or experiencing problems with communications between healthcare professionals – are 1.6 times less likely to trust the healthcare system compared to those who have not experienced such an adverse event (45% compared to 70%). In addition, 23% of patients with chronic conditions report having to repeat health information that should have been in their health records.
Digital tools could play a crucial role in addressing these challenges by improving communication, reducing errors, and enhancing care co‑ordination. For instance, integrated digital health records can ensure that vital patient information is accessible across healthcare providers and patients, minimising the need for patients to repeat their medical history.
The future of healthcare will not be doing “more of the same”. It will require a seismic shift from a short-term focus on tackling individual conditions to helping people manage several conditions over the long term.
Doing so includes simplifying websites and digital health tools to make them easier to understand, use and navigate. Older and less educated people have difficulty understanding health information and are less confident than younger people in using digital technology to manage their health. According to the PaRIS survey, in Iceland, Australia, France, Wales, Canada, Czechia and Switzerland, the more educated are at least 10 percentage points more likely to be confident in using health information from the internet. Moreover, on average people with high education are 26 percentage points more likely to say that their primary care practice website is easy to use.
There has been progress in the use of electronic health records to support better outcomes of care. However, continuity of care still suffers from poor information exchange. While electronic health records are used in 95% of the primary care practices participating in PaRIS, only half of all practices can exchange these records electronically with other practices. Practices were more likely to report being able to share electronic records in the Netherlands (97%), Belgium (92%), Norway (90%) and Australia (86%).
The use of digital tools in primary care improves person-centred care experience, but progress in their availability has been uneven. More than half (54%) of patients with chronic conditions have booked primary care appointments online, but only 17% have accessed their electronic medical records. While this is relatively common in the Netherlands (more than 50%) it is rare in countries like Czechia, Switzerland and Australia (all below 5%).
The use of videoconferences in primary care was the highest in Australia, where 36% of patients reported having done so but it is still uncommon in countries like Slovenia, Spain and the Netherlands where this was less than 3%. This highlights the critical need to improve the deployment of digital technology in primary care to enhance overall care experiences.
While there are many differences between patients there is also common ground. This report shows what patients care about when it comes to their primary care. Their voices matter. They matter in managing their own health and well-being.
PaRIS highlights the clear relationship between patients’ experiences of healthcare and health outcomes. It shows that when patients rate their primary care as good, they feel healthier. It also highlights three cornerstones of what patients care about when it comes to their care: Time, personally Tailored care and Trouble‑free care and it highlights the need to reduce gaps in experience and outcomes of care for women and people with low income and education.
Patients are people with unique, individual needs. PaRIS gives those patients a voice. It points the way for people everywhere to live longer and better lives.
