doctor statistics - canada, france, germany, italy, japan, spain, uk
TRANSCRIPT
EphMRA Foundation Committee Report – Doctor Statistics in Canada, France, Germany, Italy, Japan, Spain, UK, USA 2008
From EphMRA
This project fulfils a long standing need of international pharmaceutical researchers for
better access to doctor universe statistics. There has been a high level of interest in this
project and we hope it helps meet your needs.
The brief was to establish Doctor numbers/populations and bring this data together in one
report. This report will help researchers to have greater confidence in the representation
of doctor samples.
The sources of the data are shown and given in as much detail as possible according to
what is available in each country. Of course standardized data is not available across all
countries and so the best available has been included in this report.
This project is an EphMRA funded research project and the project was awarded after a
Request for Proposals on Doctor Statistics was sent out and the resulting proposals
evaluated.
The content of this report is confidential and intended for the sole use of EphMRA
members. We accept no liability for any errors in the report, nor from any use of the
data. Getting accurate doctor statistics can be notoriously difficult and the figures
included here should be considered as ‘reasonable best estimates’ given the variety of
assumptions underlying the data. Any assumptions made or points of clarification have
been outlined where appropriate in the report. This report reflects the work and views of
the commissioned agency and not EphMRA.
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Should you have any questions or comments about this report then please feel free to
contact EphMRA as follows:
Bernadette Rogers
EphMRA General Secretary
www.ephmra.org
Feedback is always welcomed as we use this input to further improve other funded
projects.
EphMRA Foundation Committee Report – Doctor Statistics in Canada, France, Germany, Italy, Japan, Spain, UK, USA 2008
Contents
Pg #
1 Acknowledgements 12
2 Report Author Biographies 13
3 Introduction 14
4 Objectives 15
5 Methodology 16
6 Sources of Information 17
6.1 URLs Consulted 17
6.2 Direct Consultations by e-mail, fax or telephone 20
6.3 Summary of Relevant Facts and Strategies for Updating Data 23
7 How to interpret the Statistical Data 33
8 CANADA 36
8.1 Introduction to Canada 37
8.2 Canada’s healthcare system 39
8.3 Service delivery 43
8.3.1 Public services 43
8.3.2 Primary/ ambulatory care 43
8.3.3 Secondary/inpatient, specialized ambulatory care and long term care
44
8.4 Healthcare financing and expenditure 45
8.5 Resources 46
8.6 The Canadian pharmaceuticals market 47
8.7 Bibliography 50
Table 1 Total Physicians by Specialty and Gender 51
Table 2 Total Physicians by Specialty and Age 53
Table 3 Results from the National Physician Survey 2004 Questionnaire (work Setting)
55
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9 FRANCE 56
9.1 Introduction to France 57
9.2 France’s healthcare system 59
9.3 Healthcare insurance 60
9.4 Service delivery 62
9.4.1 Public hospitals 63
9.4.2 Private hospitals 63
9.4.3 Not-for-profit hospitals 64
9.5 Healthcare financing and expenditure 64
9.6 Resources 65
9.7 The French pharmaceuticals market 66
9.8 Bibliography 70
Table 1 Total Physicians by Specialty and Gender 71
Table 2 Total Physicians by Specialty and Age 73
Table 3 Total Physicians by specialty and Major Professional Activity
75
10 GERMANY 77
10.1 Introduction to Germany 78
10.2 Germany’s healthcare system 80
10.3 Healthcare insurance 81
10.4 Service delivery 82
10.4.1 Ambulatory care 84
10.4.2 Hospital care 85
10.5 Healthcare financing and expenditure 86
10.6 Resources 87
10.7 The German pharmaceuticals market 89
10.8 Bibliography 93
Table 1 Total Physicians by Specialty and Gender 94
Table 2 Total Physicians by Specialty and Age 96
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Table 3 Total Physicians by Specialty and Major Professional Activity
98
11 ITALY 100
11.1 Introduction to Italy 101
11.2 Italian healthcare system 103
11.3 Healthcare insurance 104
11.4 Service delivery 104
11.5 Healthcare financing and expenditure 104
11.6 Resources 106
11.7 Italian pharmaceutical market 106
11.8 Bibliography 110
Table 1 Total Physicians by Specialty and Gender 111
12 JAPAN 113
12.1 Introduction to Japan 114
12.2 Japan’s healthcare system 116
12.3 Public healthcare insurance in Japan 116
12.4 Hospitals remain the first port-of-call 117
12.5 Service delivery 119
12.6 Healthcare financing and expenditure 120
12.7 Resources 121
12.8 Japanese pharmaceutical market 122
12.9 Bibliography 125
Table 1 Total Physicians by Specialty and Gender 126
Table 2 Total Physicians by Specialty and Age 128
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13 SPAIN 130
13.1 Introduction to Spain 131
13.2 Spanish healthcare system 134
13.3 Healthcare insurance 136
13.4 Service delivery 136
13.5 Healthcare financing and expenditure 137
13.6 Resources 139
13.7 Spanish pharmaceutical market 140
13.8 Bibliography 143
Table 1 Total Physicians by Specialty and Gender 144
Table 2 Total Physicians by Specialty and Age 146
Table 3a Total Physicians by Gender and Major Professional Activity, 1999
148
Table 3b Total Physicians by Age and Major Professional Activity, 1999
148
14 UK 149
14.1 Introduction to the UK 150
14.2 The UK healthcare system 151
14.3 Healthcare insurance 153
14.4 Service delivery 154
14.5 Healthcare financing and expenditure 154
14.6 Resources 156
14.7 The UK pharmaceutical market 156
14.8 Bibliography 159
England 160
Table 1 Total Physicians by Specialty and Gender 161
Table 2 Total Physicians by Specialty and Age 164
Table 3 Medical Staff by specialty and Grade 167
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Northern Ireland 171
Table 1 Total Physicians by Specialty and Gender 172
Table 2 Total Physicians by Specialty and Age 173
Table 3 Medical Staff by Specialty and Grade 174
Scotland 176
Table 1 Total Physicians by Specialty and Gender 177
Table 2 Total Physicians by Specialty and Age 180
Table 3 Medical Staff by Specialty and Grade 183
Wales 189
Table 1 Total Physicians by Specialty and Gender 190
Table 2 Total Physicians by Specialty and Age 193
Table 3 Medical Staff by Specialty and Grade 196
UK (Consolidated Data) 199
Table 1 Total Physicians by Specialty and Gender 200
Table 2 Total Physicians by Specialty and Age 202
Table 3 Medical Staff by Specialty and Grade 204
15 USA 206
15.1 Introduction to the United States of America 207
15.2 The US healthcare system 208
15.3 Healthcare insurance 209
15.4 Service delivery 211
15.5 Healthcare financing and expenditure 213
15.6 Resources 215
15.7 The US pharmaceutical market 216
15.8 Bibliography 220
Table 1 Total Physicians by Specialty and Gender 221
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Table 2 Total Physicians by Specialty and Age 223
Table 3 Total Physicians by Specialty and Professional Activity 225
Table 4 Total Physicians by Specialty, Age & Gender 234
Table 5 D.O.s by Specialty & Age 236
Table 6 Number of Osteopathic Physicians 238
Table 7 Active D.O.s by gender 238
Table 8 Active D.O.s by age category 238
Table 9 Active (in patient care) D.O.s by self-identified specialty
category
239
Table 10 Physicians by Age & Location 240
Table 11 Total Physicians by professional activity and Location 242
List of Figures
1 CANADA
Figure 1: Geopolitical map of Canada 38
Figure 2: Healthcare provision in Canada 43
2 FRANCE
Figure 3: A geographical map of France 58
Figure 4: The French healthcare system 60
3 GERMANY
Figure 5: Map of Germany showing states and key cities 79
Figure 6: Structure of the German healthcare system 80
Figure 7: German healthcare insurance coverage by type, 2003 82
Figure 8: A number of governmental bodies, physician and pharmacist associations, and industry associations impact healthcare provision in Germany
86
4 ITALY
Figure 9: Map of Italy showing key cities and regiones 102
Figure 10: Organizational structure of the Italian healthcare system 103
5 JAPAN
Figure 11: Geographical map of Japan with location and names of prefectures
115
Figure 12: Stakeholders impacting healthcare provision in Japan 119
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6 SPAIN
Figure 13: Map of Spain 132
Figure 14: Demographic distribution of Spain’s population, 2005 133
Figure 15: The Spanish healthcare system 135
Figure 16: Allocation of pharmaceutical R&D funds, 2000 141
7 UK
Figure 17: Map of the UK 150
Figure 18: Structure of the UK health service 153
8 USA
Figure 19: USA political map 207
Figure 20: Healthcare structure in the US 209
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List of Tables
1 CANADA
Table 1: Population of provinces and territories of Canada, 2002 and 2006 39
Table 2: An overview of services, financing and delivery within the Canadian healthcare system
44
Table 3: Canadian healthcare spending statistics, 2003 45
Table 4: Canadian physician and nurse numbers 46
Table 5: Pharmaceutical sales (Ex - mfr; Constant 2005 US$) 47
Table 6: Canadian retail sales by therapeutic category, 2005 48
2 FRANCE
Table 7: French healthcare spending statistics 65
Table 8: French physician and nurse numbers 65
Table 9: French retail sales by therapeutic category, 2005 66
Table 10: Pharmaceutical reforms in France, 2001-2006 68
3 GERMANY
Table 11: German healthcare spending statistics 87
Table 12: German physician and nurse numbers 88
Table 13: The German Hospital sector – Key figures 1991 and 2004 89
Table 14: Pharmaceutical reforms in Germany, 2000-2006 92
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4 ITALY
Table 15: Italian healthcare spending statistics 105
Table 16: Italian physician and nurse numbers 106
Table 17: Italian retail sales by therapeutic category, 2005 107
Table 18: Pharmaceutical reforms in Italy, 2001-2006 108
5 JAPAN
Table 19: Key Japanese health expenditure indicators, 2004 120
Table 20: Physicians and Nurses 121
Table 21: The number of hospitals, GP clinics, dental clinics, plus beds, in Japan in 2001
122
Table 22: Japanese pharmaceutical sales by therapeutic category, 2005 123
6 SPAIN
Table 23: Spanish healthcare spending statistics 138
Table 24: Spanish physician and nurse numbers 139
7 UK
Table 25: Key health expenditure indicators 155
Table 26: UK physicians and nurses, 2005 156
Table 27: UK retail sales by therapeutic category, 2005 157
Table 28: Evolution of generic / brand share of market value in the UK, 2000-2004
158
8 USA
Table 29: Leading Types of Private Insurance in the US 210
Table 30: Source of Health Coverage 211
Table 31: Access to healthcare providers according to different health plans
213
Table 32: Key US health expenditure indicators, 2005 214
Table 33: Sources of US health spending, 2004 214
Table 34: Destination of Health Spending, 2004 215
Table 35: Physicians and Nurses 216
Table 36: Generic and branded trends in the US, 2004-2005 217
Table 37: US retail sales by therapeutic category, 2005 218
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1. Acknowledgements
We would like to thank the following people for their help and time given to this project.
Without their assistance this report could not have been completed successfully:
o Holly Bodger (Electronic Publishing Manager, Canadian Medical Association,
Canada)
o Dr. ssa Anna Rita Mascolini (Federazione Nazionale degli Ordini dei, Italy)
o Dr. Massimo Fabri (FIMMG Nazionale, Italy)
o Ms.Tanabe (Ministry of Health Labour and Welfare, Japan)
o Dr Miguel Angel García Pérez (Fundación CESM, Spain)
o Naomi Sang (The Information Centre for health and social care, UK)
o Jacqueline Liddicoat (Department of Health, Social Services and Public Safety,
Northern Ireland)
o Celina Davis (Healthcare Information Group, Scotland)
o Vivien Trew (Health Statistics and Analysis Unit, Wales)
Whilst every effort has been made to keep errors to a minimum, we recognize that minor
faults can occur. Please contact us via EphMRA if you spot any mistakes and
inaccuracies within this report. This report reflects the views and research of the
commissioned team, the Datamonitor Healthcare Consulting Team, rather than EphMRA.
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2. Report Author Biographies
The team from Datamonitor Healthcare Consulting comprised of four key members
headed up by Dr Duncan Emerton, Managing Consultant within the group. Assistance
was provided by Venkateshwara Rao Gunnam (Senior Consultant), Aparna Anantharaju,
(Associate Consultant), and Shilpa Didla (Associate Consultant).
Dr Duncan Emerton, Managing Consultant (Project Director)
Dr Emerton joined Datamonitor in December 2004 from Pfizer Global Pharmaceuticals
(UK) Ltd. During his tenure at Pfizer his primary focus was on Pfizer’s endocrinology
portfolio where he was involved in clinical development, sales and marketing activities.
Prior to joining Pfizer, Dr Emerton worked in a variety of roles within pre-clinical and
clinical drug development, during which he gained experience in the implementation and
management of Phase I–IV clinical trials for several pharmaceutical and biotechnology
companies—including Sanofi-Synthélabo, Merck & Co, Pharmacia, ExonHit
Therapeutics SA and Cytos Biotechnology AG—mainly in the areas of cardiology,
neurology and vaccines. Since joining Datamonitor, Dr Emerton has worked on company
analysis, therapy area analysis focused on the cardiovascular market and is currently
involved in projects focusing on new product market assessments, providing market
forecasting support, assessing the impact of generics on branded pharma companies and
supporting licensing deals for EU pharma companies. Dr Emerton holds a PhD in
Microbial Biotechnology from the University of Kent and a BSc (Hons) in Medical
Biochemistry from the University of Surrey. Dr Emerton can be reached at
[email protected] or +44 (0) 20 7675 7000.
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3. Introduction
Following the completion of the Doctor Universe Statistics Report in 2003, the EphMRA
Foundation Committee looked to update and expand its research to include new
countries/regions and specialties. Subsequently, EphMRA initiated an update of the 2003
Doctor Universe Statistics Report to ensure data is as up to date as possible. Datamonitor
Healthcare Consulting submitted a proposal to update the report, which was accepted by
EphMRA.
The structure of this report will be as follows:
o Objectives
o Research methodology
o Main findings of the research of each country/region broken down into qualitative
and quantitative reports
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4. Objectives
The objectives of this research were as follows:
o The primary objective of this project is to update the physicians statistics in the
original report (published in 2003) and where possible augment the study with
additional data describing the physician landscape in each of USA, Japan,
France, Germany, Italy, Spain, UK and Canada.
o Establish mechanisms for the periodical update of this information.
o Create a list of the sources used and contacted for update of this report and create
a database.
o New for 2007/8: provide a comprehensive qualitative section for each country
explaining: the healthcare system, payment and reimbursement, how healthcare is
delivered – e.g. the role of community vs. hospital HCPs, pharmacists and dentists
(also includes nurses), urban vs. rural distribution, explanations about specialty
nomenclature and categorization
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5. Methodology
The study consists of three parts:
o Using information sources identified in 2003 report identify directly published
updates of statistics from relevant country authorities.
o Supplement the sources (identified in 2003 report) with additional country
specific sources by a thorough secondary research program.
o Where gaps in the data are still present contact relevant health authorities directly
in each country to assess potential current or future availability of data.
o In this part of the project, the physician’s statistical data were analyzed and
tabulated. The data is tabulated in the Microsoft Excel program for each of the
countries covered for easy usage and is also compiled in Microsoft Word as a
report.
PART II
PART I
PART III
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6. Sources of Information 6.1. URLs consulted The URLs (websites) that were consulted by country were as follows: CANADA
FRANCE GERMANY
ITALY
Italian Medical Association http://fnomceo.it/Servizi/STATISTICA%20LUGLIO%202005/sta%207_2005.htm Italian General Practitioners / Family Doctor Association http://www.fimmg.org/
The German Medical Association http://www.bundesaerztekammer.de/page.asp?his=0.3.5008
The French Medical Council (Le Conseil National De l’Ordre des Medecins: Exercise Professionnel). http://www.conseil-national.medecin.fr/?url=demographie/index.php&open=3#3
Canadian Medical Association http://www.cma.ca/index.cfm/ci_id/16959/la_id/1.htm#1 Canadian Institute for Health Information http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=statistics_results_topic_physicians_e National Physician Survey http://www.nationalphysiciansurvey.ca/nps/results/physicians-e.asp
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JAPAN
SPAIN
UK
England The Information Centre, National Health Service http://www.ic.nhs.uk/statistics-and-data-collections/workforce/nhs-staff-numbers/nhs-hospital-and-community-staff-hchs-2006 Northern Ireland Department of Health, Social Service and Public Safety http://www.dhsspsni.gov.uk/index/stats_research/work_force/stats-research.htm#wfcurpubs Scotland Information Services Division, NHS National Services Scotland http://www.isdscotland.org/isd/workforce-statistics.jsp?pContentID=1348&p_applic=CCC&p_service=Content.show& Wales The National Assembly for Wales http://www.statswales.wales.gov.uk/ReportFolders/reportfolders.aspx?IF_ActivePath=P,280,1274
Ministry of Health and Consumption http://www.msc.es/novedades/docs/necesidadesEspeciales06_30.pdf
Statistics Bureau Director General for Policy Planning (Statistical Standards) & Statistical Research and Training Institute http://www.stat.go.jp/data/nenkan/zuhyou/y2122000.xls
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USA
American Medical Association: Physician Statistics http://www.aoa-net.org/ American Osteopathic Association http://www.osteopathic.org/index.cfm?PageID=aoa_annualrprt
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6.2. Direct consultations by e-mail, fax or telephone.
Direct Contact Holly Bodger Electronic Publishing Manager, Canadian Medical Association 1867 Alta Vista Drive Ottawa, Ontario K1G 3Y6 Tel: 613-731-8610 x 2281 Fax: 613-565-7704 E-mail: [email protected]
Direct Contact Dr. ssa Anna Rita Mascolini Manager of the international department FNOMCeO Federazione Nazionale degli Ordini dei Piazza Cola di Rienzo 80/A 80/A - 00192 Roma. Tel: 06362031 E-mail: [email protected] Direct Contact Dr. Massimo Fabri Centro Studi FIMMG Nazionale FIMMG Nazionale (Italian General Practitioners / Family Doctor Association) Piazza G. Marconi, 25 00144 Roma. Tel: 0654896625 E-mail: [email protected]
Direct Contact Ms.Tanabe, Statistics and Information Department, Ministry of Health Labour and Welfare, Japan Tel:03-5253-1111/03-3595-2958 E-mail id: [email protected]
JAPAN
ITALY
CANADA
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Direct Contact Dr Miguel Angel García Pérez Fundación CESM c/ Veneras 9-4º 28013 Madrid Tel: +34 91 559 14 02 E- mail id: [email protected]
England Direct Contact Naomi Sang Workforce Information Officer, The Information Centre for health and social care, 1 Trevelyan Square, Boar Lane, Leeds, LS1 6AE. Tel:0113 2547270 E-mail id: [email protected] Northern Ireland Direct Contact Jacqueline Liddicoat Workforce Statistics Department of Health, Social Services and Public Safety, Northern Ireland Government Tel: 028 9052 2509 E-mail id: [email protected] [email protected]
SPAIN
UK
22
Scotland Direct Contact Celina Davis Costs & Workforce Team Healthcare Information Group ISD Scotland Gyle Square, 1 South Gyle Crescent Edinburgh, EH12 9EB Tel: 0131 275 6199 E-mail id: [email protected] Wales Direct Contact Vivien Trew Health Statistics and Analysis Unit Welsh Assembly Government Tel: (029) 2082 5080 f: (029) 2082 5350 E-mail id: [email protected]
Physician Characteristics and Distribution in the US 2007 Edition Author: AMA Bibliographic Data ISBN: 978-1-57947-782-0, 400 pages, soft cover. Mail Orders Order Department American Medical Association PO Box 930876 Atlanta, GA 31193-0876 Call Toll Free Tel:800 621-8335 Fax: 312 464-5600 Secure Online Orders www.amabookstore.com
USA
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6.3. Summary of relevant facts and strategies for updating data CANADA
Relevant facts
o Statistics related to the physician numbers by specialty & gender and specialty & age group in Canada are available from Canadian Medical Association (CMA).
o Statistics related to the Physician numbers by nature of work setting are available from National Physician Survey, carried out by the College of Family Physicians of Canada (CFPC), the Canadian Medical Association (CMA) and the Royal College of Physicians and Surgeons of Canada (RCPSC) and the Canadian Institute for Health Information and Health Canada.
Strategies for updating data
o Physician statistics by specialty & gender and specialty & age group are updated regularly by the Canadian Medical Association (CMA). So the best strategy is to check the URL (website) address of CMA.
o Physician statistics by professional activity is collated from the National Physician Survey. The survey is carried out once in every 3 years. The survey for 2007 was completed in November 2007.
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FRANCE
Relevant facts
o Physician statistics in France are available from The French Medical Council (Ordre National des Medecins; Conseil National de l'Ordre) by specialty & gender, specialty & age group and by specialty & professional activity.
Strategies for updating data
o The data is updated by "The French Medical Council (Ordre National des Medecins; Conseil National de l' Ordre)" annually. So it is recommended to check the URL (website) address of this association.
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GERMANY
Relevant facts
o Physician statistics in Germany are available from "The German Medical Council (Bundesarztekammer)" by specialty & gender, specialty & age group and by specialty & professional activity.
Strategies for updating data
o The frequency of data update by "The German Medical Council (Bundesarztekammer)" is annually. So it is recommended to check the URL (website) address of this association.
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ITALY
Relevant facts
o Only statistics sorted by specialty and age could be obtained in Italy.
o Italian physician statistics sorted by specialty & gender are available from FNOMCeO (Federazione Nazionale degli Ordini dei - Italian Medical Council).
o GP statistics sorted by specialty and age are provided by FIMMG Nazionale (Italian General Practitioners / Family Doctor Association).
Strategies for updating data
o The frequency of data update by "The Italian Medical Council (FNOMCEO)" is not clearly known. 2005 physician statistics are available on the FNOMCEO website; however, supplemental but un-published statistics were provided by the Italian Medical Council when contacted directly.
o The best strategy for regular updates therefore is to be contact FNOMCEO for the latest available statistics.
o GP statistics are updated by FIMMG Nazionale (Italian General Practitioners / Family Doctor Association) annually and data can be obtained by contacting the association.
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JAPAN
Relevant facts
o Physician statistics in Japan are available from "Data based on the survey of Physicians, Dentists and Pharmacists". This is collated by Statistics and Information Department, Minister's Secretariat, Ministry of Health, Labour and Welfare (MHLW).
o The data can be obtained directly from the Statistics and Information Department of MHLW.
o The data is available by main field of specialty, gender and age group.
o General practitioners/ Family Doctors in Japan work as GPs with an additional specialty.
o In Japan, cancer is treated by individual specialists based on the location of tumor.
Strategies for updating data
o The frequency of data update by the Statistics and Information Department, Ministry of Health, Labour and Welfare is not known. There is no update/ survey undertaken since 2004.
o The best strategy is to get into direct contact with the Statistics and Information Department, Ministry of Health, Labor and Welfare and request for the latest version of "Survey of Physicians, Dentists and Pharmacists". The survey results are available in Japanese language and need to be translated into English.
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SPAIN
Relevant facts
o CESM Foundation (Confederacion Espanola de Sindicatos Medicos) provides the number of physicians by specialty and gender.
o The 2005 data for the current report has been obtained by contacting the CESM. The data was taken from a report published by the Ministry of Health and Consumption, Spain, that has been compiled from multiple sources: regional health service workforces, hospital statistics, etc.
o The data for the number of physicians by professional activity have not been updated by the CESM since the survey from which the numbers were obtained in the older report (2003), has not been conducted again.
Strategies for updating data
o For any updates regarding the physicians, it is recommended to approach the CESM and the Ministry of Health and Consumption, in order to find out the latest dates of data updating.
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UK
Relevant facts England
o The Physician numbers by specialty & Gender, specialty & age and specialty & professional activity can be obtained from The Information Centre, Medical and Dental Workforce Census, National Health Service (NHS).
Northern Ireland
o Statistics related to the physician numbers by specialty in Northern Ireland has to be directly requested from the Workforce Statistics, Department of Health, Social Services and Public Safety.
o Statistics related to the General Practitioners in Northern Ireland is available from Medical Directorate, Central Services Agency.
Scotland
o Statistics related to the physician numbers by specialty & gender, specialty & age and specialty & professional activity can be sourced from Information and Statistics Division, National Health Service, Scotland.
Wales
o Statistics related to the physician numbers in Wales is available from The National Assembly for Wales.
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UK Strategies for updating data England
o Physician statistics by specialty & gender and specialty & professional activity are updated annually by The Information Centre, Medical and Dental Workforce Census, National Health Service (NHS) and can be accessed by checking the URL (website) address.
o Physician statistics by specialty and age has to be requested directly from The Information Centre, Medical and Dental Workforce Census, National Health Service (NHS) and is not available at the URL (website) address.
Northern Ireland
o In some of the specialties, there are very limited numbers of physicians in Northern Ireland. Hence, to avoid the issue of 'Disclosure of personal information', the data is not published by the Workforce Statistics, Department of Health, Social Services and Public Safety.
o However, on contacting the authorities, the information related to 'specialty and gender' can be obtained from the Workforce Statistics division, Department of Health, Social Services and Public Safety.
o Statistics related to the General Practitioners can be sourced from the URL (website) address.
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UK
Strategies for updating data Scotland
o Physician statistics by specialty & gender, specialty & age group and specialty & professional activity is published annually by the Information and Statistics Division, National Health Service, Scotland. This data can be accessed by checking the URL (website) address.
Wales
o Physician statistics by specialty & gender, specialty & age group and specialty and professional activity are updated annually by the National Assembly for Wales in its Statistics for Wale’s database.
o However, the data for this report has been obtained by contacting the Health Statistics and Analysis Unit as the latest data available on their website is for the year 2005.
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USA
Relevant facts
o The data for the number of Physicians by specialty, gender, age, major professional activity is published by the American Medical Association.
o The data for the current report has been obtained from the AMA publication titled, "Physician Characteristics and Distribution in the US, 2007 Edition". This Edition contains the data for the year 2005.
o The updated version of this purchased report, with the data for 2006, will be available by the month of December, 2007.
o The Osteopathic physician numbers can be obtained from the American Osteopathic Association Website.
Strategies for updating data
o "Physician Characteristics and Distribution in the US" is a statistical report on the US physicians that is published every year, by the American Medical Association.
o To update the data, this report can be purchased from the AMA, the purchase details can be found on the Associations Website.
o The Osteopathic Physician numbers are updated and published annually, by the American Osteopathic Association on their Website
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7. How to interpret the statistical data
o The physician statistics in each of the countries covered in the project scope was categorized into three tables:
• Table No.1 Physicians by specialty and gender • Table No.2 Physicians by specialty and age • Table No.3 Physicians by specialty and main professional activity
o Table No.1 includes the physician statistics, by specialty, distribution by gender and the proportion of each gender by specialty.
o Table No.2 includes the physician statistics by specialty, and their distribution into the following age groups: under 35, from 35 to 44, from 45 to 54, from 55 to 64 and 65 and over.
o As there is a wide variation in the availability of the specialist data by main professional activity, there is a variation in the data included in Table 3 across the countries and is described in special situations section.
o The statistics are presented by covering in detail the various specialties. The specialties break up in each country is as per the official data availability in the respective countries.
o All the data in the various tables correspond to the ‘Active Physicians’ – practicing physicians. Statistics in France and United States includes data other than the active physicians like unemployed physicians, retired physicians or physicians exercising a professional activity other than patient care.
o In each of the tables, the total number of physicians is presented in the beginning and in bold, for a fast reference of the total number of physicians.
o To facilitate data comprehension, the specialties were organized into alphabetical order, using the same terminology.
o At the end of each table can be found the specialties and sub specialties included in a more general or well known specialty, and the source of the data.
GENERAL CRITERIA
34
o Italy includes only Table No.1 (specialties per gender).
o Japan does not include Table No. 3 (specialties per activity).
o The age group distribution in Table No.2 is different in the following countries as the official data is available only in those age groups:
• In Germany, the German Medical Association provides the data in with the age distribution into the following age groups: under 34, from 35 to 39, from 40 to 49, from 50-59, from 60 to 53 and from 66 and over.
• In Spain, the CESM Foundation (Confederacion Nacional de Sindicatos Medicos) uses age distribution into the following age groups: under 36, from 36 to 45, from 46 to 55, from 56 to 65 and 65 and over.
o In accordance with the official data availability in each of the countries covered, Table No. 3 has the following characteristics:
• The statistics in Germany, France and United States are presented by specialty and by the activity as given below:
§ Office based § Hospital based § Other (different from patient care)
• In Canada the data coverage is based on the Physician Resource Questionnaire survey results. The data distribution covers the physician’s preferences for various types of practice settings.
SPECIFIC SITUATIONS
35
• Since 1999, there was no survey being undertaken in Spain for the statistics related to the professional activity of the physicians. As per the study in the year 1999, data was grouped according to gender and age, in terms of:
§ Activity in the private sector § Activity in the public sector (public sector GPs, specialist
physician public sector, other activities public sector) § MIR (Physicians in training) § No professional practice
• In UK the data is distributed according to the form or grade in which the activities in the Hospitals of the Public Health System are organized hierarchically, functionally and employment-wise by specialty. The main grades are as follows:
§ Consultant (including Director of Public Health) § Staff Grade § Associate Specialists § Registrar Group / Specialist Registrar § Senior House Officers / Foundation Year 2 § House Officers / Foundation Year 1 § Hospital Practitioner / Clinical Assistant
o In Spain & Northern Ireland, as the physician statistics by specialty and age groups / grades were not available, estimated data was presented. The assumption was the break up (proportion) of the specialists into various age groups/ grades to the total number of physicians in each specialty is similar to that of in the earlier published report in the year 2003. The statistics by specialty and distribution by gender is available in these countries.
o In Northern Ireland, the data is not available owing to the issue of personal information disclosure.
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8. Canada
37
8.1. Introduction to Canada Canada is a country occupying most of northern North America, and is the world's
second-largest country by total area, extending from the Atlantic Ocean to the Pacific
Ocean and northward into the Arctic Ocean. Canada shares land borders with the United
States to the north-west and south. Inhabited first by aboriginal peoples, Canada was
founded in 1867 as a union of British colonies (some of which were formerly French
colonies). It gained independence from the United Kingdom in an incremental process
that ended in 1982. It remains a Commonwealth Realm with Queen Elizabeth II as its
Head of State.
Canada is a federal constitutional monarchy with parliamentary democracy. Comprising
10 provinces and three territories (Figure 1), it is a bilingual and multicultural country,
with both English and French as official languages at the federal level. A technologically
advanced and industrialized nation, Canada maintains a diversified economy that is
heavily reliant upon its abundant natural resources and upon trade—particularly with the
US, with which Canada has had a long and complex relationship.
38
Figure 1: Geopolitical map of Canada
Source: www.wikipedia.org D A T A M O N I T O R
The provinces are responsible for most of Canada's social programs (such as health care,
education, and welfare) and together collect more revenue than the federal government,
an almost unique structure among federations in the world. Using its spending powers,
the federal government can initiate national policies in provincial areas, such as the
Canada Health Act; the provinces can opt out of these, but rarely do so in practice.
Equalization payments are made by the federal government to ensure that reasonably
uniform standards of services and taxation are kept between the richer and poorer
provinces. All provinces have unicameral, elected legislatures headed by a Premier
selected in the same way as the Prime Minister of Canada. Each province also has a
Lieutenant-Governor representing the Queen, analogous to the Governor General of
39
Canada, appointed on the recommendation of the Prime Minister of Canada, though with
increasing levels of consultation with provincial governments in recent years.
At the end of 2006, Canada’s population was approximately 32.6 million, 85% of whom
were residents of only four provinces—Ontario, Quebec, British Columbia and Alberta.
Between 2002 and 2006, Canada’s population remained relatively stable, growing by less
than 1% from 31.4 million in 2002 to 32.6 million in 2006 (Statistics Canada,
www.statcan.ca; accessed May 2007).
Table 1: Population of provinces and territories of Canada, 2002 and 2006
Province Population
2002 Population
2006
Growth 2002-06
(%) Ontario 12,102,000 12,687,000 0.95 Quebec 7,445,700 7,651,500 0.55 British Columbia 4,115,400 4,310,500 0.93 Alberta 3,116,300 3,375,800 1.61 Manitoba 1,155,600 1,177,800 0.38 Saskatchewan 995,900 985,400 -0.21 Nova Scotia 934,500 934,400 0.00 New Brunswick 750,300 749,200 -0.03 Newfoundland and Labrador 519,400 509,700 -0.38 Prince Edward Island 136,900 138,500 0.23 Northwest Territories 41,500 41,900 0.19 Yukon Territory 30,100 31,200 0.72 Nunavut 28,700 30,800 1.42 Total 31,372,300 32,623,700 0.79
Source: www.statcan.ca D A T A M O N I T O R
8.2. Canada’s healthcare system Canada's healthcare system has been a work in progress since its inception. Reforms have
been made over the past four decades and will continue in response to changes within
medicine and throughout society. The basics, however, remain the same - universal
coverage for medically necessary healthcare services provided on the basis of need, rather
than the ability to pay.
40
Canada's national health insurance program, often referred to as ’Medicare‘, is designed
to ensure that all residents have reasonable access to medically necessary hospital and
physician services, on a prepaid basis. Instead of having a single national plan, it has a
national program that is composed of 13 interlocking provincial and territorial health
insurance plans, all of which share certain common features and basic standards of
coverage. Framed by the Canada Health Act (CHA), the principles governing the
healthcare system are symbols of the underlying Canadian values of equity and solidarity.
Roles and responsibilities for Canada's healthcare system are shared between the federal
and provincial-territorial governments. Under the Canada Health Act, the federal health
insurance legislation, criteria and conditions are specified that must be satisfied by the
provincial and territorial healthcare insurance plans in order for them to qualify for their
full share of the federal cash contribution, available under the Canada Health Transfer
(CHT). Provincial and territorial governments are responsible for the management,
organization and delivery of health services for their residents.
Primary healthcare is the foundation of the Canadian healthcare system, and is the first
point of contact people have with the healthcare system. This could be through a doctor, a
nurse, another health professional, or perhaps through phone or computer-based services.
Primary healthcare involves providing services, through teams of health professionals, to
individuals, families and communities. It also incorporates a proactive approach to
preventing health problems and ensuring better management and follow-up once a health
problem has occurred. These services are publicly funded from general tax revenues
without direct charges to the patient.
A patient may be referred for specialized care at a hospital or long-term care facility or in
the community. The majority of Canadian hospitals are operated by community boards of
trustees, voluntary organizations or municipalities. For the most part, healthcare services
provided in long-term institutions are paid for by the provincial and territorial
governments, while room and board are paid for by the individual; in some cases these
payments are subsidized by the provincial and territorial governments.
41
Alternatively, healthcare services may be provided in the home and/or community.
Referrals to home care can be made by doctors, hospitals, community agencies, families
and potential residents. These services, such as specialized nursing care, homemaker
services and adult day care, are provided to people who are partially or totally
incapacitated. Needs are assessed, and services are coordinated to provide continuity of
care and comprehensive care.
The provinces and territories also provide coverage to certain groups of people (e.g.,
seniors, children and social assistance recipients) for health services that are not generally
covered under the publicly funded healthcare system. These supplementary health
benefits often include prescription drugs, dental care, vision care, medical equipment and
appliances (prostheses, wheelchairs, etc.), independent living and the services of allied
health professionals, such as podiatrists and chiropractors. The level of coverage varies
across the country. Many Canadians have supplemental private insurance coverage
through group plans, which covers the cost of these supplementary services.
Canada has a predominantly publicly financed health system with services provided
through private (for-profit and not-for-profit) and public (arm’s-length or state-run)
bodies. There are 13 single-payer, universal systems for “medically necessary” services –
largely hospital and physician services which are “insured services” under the federal
Canada Health Act. The 13 provinces and territories vary considerably in terms of the
financing, administration, delivery modes and range of public health care services. The
federal government is responsible for collecting and providing health data, research and
regulatory infrastructure, in addition to directly financing and administering a number of
health services for selected population groups.
Under the Canada Health Act, all residents of a province are eligible to receive “insured
services” free at the point of delivery. These “insured services” under the Act include
virtually all hospital, physician (including some dental surgery) and diagnostic services.
Services excluded from this package include most dental care, most vision care, long-
term care, home care, and pharmaceuticals prescribed outside of hospitals. According to
42
the Health systems in Transition (HiT) report, 33.8% of all prescription drugs, 21.7% of
all vision care and 53.6% of all dental care are funded through private health insurance
(HiT Summary, World Health Organisation, 2005). Provinces vary in the extent to which
non-Canada Health Act insured services are covered or subsidized in the provincial
health plans. Out-of-pocket payments constitute the most important source of financing
for private health goods and services, like vision care, over-the-counter medication, and
complementary and alternative medicines and therapies. About 20% of prescription drugs
are financed through out-of-pocket payments.
The third largest source of health care financing is complementary private health
insurance. The majority of private health insurance is employment-based insurance and
designed to provide coverage for health goods and services not covered by Medicare
(Canada's national health insurance program). Although largely employment-based and
paid for by employees and employers (and in few cases purchased solely by individuals,
e.g. the self-employed), private health insurance is supported through tax expenditure
subsidies. Private health insurance that attempts to provide a private alternative to
medically necessary hospital and physician services is prohibited by a range of provincial
regulations. Figure 2 gives an overview of the healthcare provision in Canada.
43
Figure 2: Healthcare provision in Canada
Source: Health systems in transition, 2005 D A T A M O N I T O R
8.3. Service delivery
8.3.1. Public services The federal, provincial and territorial governments, as well as regional health authorities,
perform discrete functions like population health assessment, disease and injury control
and emergency preparedness. In addition, the Canadian Public Health Association is a
voluntary organization dedicated to improving the state of public health in Canada.
8.3.2. Primary/ ambulatory care Family physicians, serve as the patient’s first point of contact; they are gate-keepers to
higher levels of the health system. Patients are free to choose a family physician who
typically works independently on a fee-for-service basis. Increased focus on primary care
has been associated with some jurisdictions replacing fee-for-service remuneration with
alternative payment contracts for physicians, improving access to essential services, and
44
accelerating the development of telehealth applications in rural and remote areas of the
country.
8.3.3. Secondary/inpatient, specialized ambulatory care and long term care
All secondary, tertiary and emergency care, as well as the majority of specialized
ambulatory care and elective surgery, is performed within hospitals. Hospitals specialize
in acute and emergency care, while primary care is left to family physicians or
community-based facilities, and long-term care to nursing homes and similar institutions,
which are either run by the regional health authorities, or are independent private-for-
profit or not-for profit organizations. Table 2 gives an overview of financing and delivery
of the main healthcare services in Canada.
Table 2: An overview of services, financing and delivery within the Canadian healthcare system
Service Financing Delivery
Hospitals
100% publicly funded for medically necessary services, private payment for upgraded
accommodations or services not deemed medically necessary
Mix of public and private hospitals, but all
are non-profit and are highly regulated.
Physicians
100% publicly funded for medically necessary services; private payment services not deemed medically necessary.
Physicians are in private practice and paid by
Medicare on a fee-for-service basis
Dentists and Optometrists
Mostly private although some provinces provide public funding
for children and the elderly Private
Prescription Drugs
Mix of public and private (supplemental insurance + out of
pocket) payment with 60/40 emphasis on private payment.
(Applies to retail channel/Products consumed in hospitals are paid
publicly.) With the exception of British Columbia. Private
Non-Prescription Drugs Private (Out-of-Pocket) Private
Source: internal secondary research D A T A M O N I T O R
45
8.4. Healthcare financing and expenditure
Within the publicly funded healthcare system, health expenditures vary across the
provinces and territories. This is, in part, due to differences in the services that each
province and territory specifies to be medically necessary and to demographic factors
such as a population's age. Other factors, for example, areas where there are small and/or
scattered populations, may also have an impact on healthcare costs. Table 3 illustrates
WHO statistics derived from the World Health Statistics 2006 and The World Health
Report, 2006 Edition.
Table 3: Canadian healthcare spending statistics, 2003
Indicator Value 2003
Total expenditure on health as percentage of gross domestic product 9.9% General government expenditure on health as percentage of total expenditure on health
69.9%
Private expenditure on health as percentage of total expenditure on health 30.1% General government expenditure on health as percentage of total government expenditure
16.7%
External resources for health as percentage of total expenditure on health 0.0% Social security expenditure on health as percentage of general government expenditure on health
2.1%
Out-of-pocket expenditure as percentage of private expenditure on health 49.6% Private prepaid plans as percentage of private expenditure on health 42.3% Per capita total expenditure on health at average exchange rate US$2,669 Per capita total expenditure on health at international dollar rate US$2,989 Per capita government expenditure on health at average exchange rate US$1,866 Per capita government expenditure on health at international dollar rate US$2,090
Source: WHO sources World Health Statistics 2006 and The World Health Report,
2006 Edition D A T A M O N I T O R
According to the Canadian Institute for Health Information, total health expenditure in
Canada was $131.4 billion in 2004, with this number expected to grow to $139.8 billion
in 2005 and $148.0 billion in 2006, a year-on-year increase of 6.4% and 5.9%,
respectively. Health expenditure in 2004 continued the trend of relatively strong growth
that has been seen since 1997, following 6 years when annual growth rates averaged
0.8% in real terms. The modest rates of growth during the early to mid-1990s reflected a
46
flattening of the historic growth curve. From 1975 to 1991 the annual average rate of
growth was 3.8%. The trend since 1997 appears to be largely due to reinvestment by
federal, provincial and territorial governments after a period of fiscal restraint during the
early and mid-1990s (Canadian Institute for Health Information. National Health
Expenditure Trends, 1975–2005).
8.5. Resources Despite the high level of health expenditure in Canada, there are few physicians per
capita. In 2005, Canada had only 2.2 practicing physicians per 1,000 population and 10
qualified nurses per 1,000 population. The number of nurses per capita has started to rise
since 2002. Table 4 gives the absolute number and density of physicians and nurses in the
recent years.
Table 4: Canadian physician and nurse numbers
Resource indicator Value (year) Physicians (number) 66, 583 (2003) Physicians (density per 1,000 population) 2.2(2005) Nurses (number) 309, 576 (2003) Nurses (density per 1,000 population) 10.0 (2005)
Source: OECD Healthcare Statistics, various years are indicated D A T A M O N I T O R
The number of acute care hospital beds in Canada was 2.9 per 1, 000 population in 2004
(OECD Health data, 2007). There has been a decline in the number of hospitals in the
recent years. There was a 20% drop in the total number of hospitals offering inpatient
care from the mid-1980s to the mid- 1990s and hospital admissions declined by 12.8%
from 1995 to 2001. However, on the whole, average length of stay actually increased by
1.4%, with considerable variation across provinces. For a complete review of the most up
to date physician statistics, please refer to the Canadian physician statistics section of this
report.
47
8.6. The Canadian pharmaceuticals market
There is increasing demand for new pharmaceuticals in Canada due to the ageing
population and high per-capita consumption. But extremely long approval times,
mandatory low prices, spotty patent protection and complex regulations, which vary from
province to province are some negative factors of the Canadian market.
The Canadian pharmaceutical market amounted $13.68 billion in 2005 (internal
secondary research; see bibliography for details), translating to spending of $429 per
person. The Canadian pharmaceutical industry employs about 22,000 people. Branded
products accounted for 57% of prescriptions and 82% of sales in 2005. In the retail
channel, generics accounted for 43% of prescription volume and 18% of value in 2005.
Generics are not subject to price controls and are 78% higher, on average than in the US.
Generic substitution is allowed by law.
As indicated in table 4, retail pharmacies, which accounted for 88.4% of total sales, grew
more slowly (6.4%) than hospitals (14.5%) in the 2004-2005 period. The relatively high
levels of hospital growth can be attributed to increased use of expensive
biopharmaceuticals and oncology therapies. Retail performance was slowed because of
patents expirations; a lack of major launches; cost containment measures etc. At end-user
prices, OTC sales accounted for 16.8% of sales (internal secondary research; see
bibliography for details).
Table 5: Pharmaceutical sales (Ex - mfr; Constant 2005 US$)
Year
Retail Sales
$m Growth Retail as %
of total
Hospital Sales
$m Growth
Total Sales
$m Growth 2004 11,364 9.7% 89.2% 1,386 8.3% 12,742 9.6% 2005 12,090 6.4% 88.4% 1,585 14.5% 13,675 7.3%
Source: internal secondary research D A T A M O N I T O R
48
The following table shows retail sales by therapeutic category in 2005. Almost 45% of
retail sales were made by cardiovascular and central nervous system therapeutic
categories.
Table 6: Canadian retail sales by therapeutic category, 2005 Category $m % Change Cardiovascular 3,017 8% Central Nervous System 2,367 7% Alimentary/ Met 1,721 5% Respiratory 878 9% Anti-Infectives 619 7% Musculoskeletal 683 -10% Genitourinary 582 5% Cytostatics 638 13% Blood Agents 345 14% Dermatologicals 405 6% Sensory Organs 217 9% Diagnostic Agents 274 10% Systemic Hormones 99 9% Miscellaneous 122 9% Hospital Solutions 3 -13% Parasitology 25 13% Total 11,995 8%
Source: internal secondary research D A T A M O N I T O R
R&D spending in Canada has declined in recent years, with total R&D spending falling
by 2% year-on-year since 2003. Of this R&D spending, investment in industry-sponsored
clinical trials $419/person in 2004 (Calon, 2006). Additionally, Canada is a major source
of grey market drugs coming into the United States. The combination of internet
technology and mail order pharmacies greatly increased the prevalence of the practice.
However, due to increased focus on drug safety, patent expiration on a number of leading
drugs, strengthening of the Canadian versus the US dollar and restricted availability of
supplies, cross-border trade declined from $491 million in 2004 to $351 million in 2005
(internal secondary research; see bibliography for details). Canada maintains a high level
of population health and has undergone a series of reforms. Some challenges like the
49
ageing population, increasing health care expenditure, particularly for pharmaceuticals,
lengthy waiting times, and shortages of human resources, need to be addressed.
50
8.7. Bibliography
o Calon, F. (2006). Non-patentable drugs and the cost of our ignorance. CMAJ. 174
(4).
o World Health Organization (2005) Health systems in transition 2005 [Internet].
WHO Regional Office for Europe on behalf of the European Observatory on
Health Systems and Policies. Available from:
http://www.euro.who.int/Document/E87954.pdf> [Accessed October 2007].
o World Health Organization (2007) World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=can&indicators=selected&language=en> [Accessed October 2007].
o World Health Organization (2007) World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=can&indicators=healthpersonnel> [Accessed October 2007].
o OECD data (2007) OECD Health data 2007 [Internet]. Available from:
<http://www.oecd.org/dataoecd/46/33/38979719.pdf> [Accessed October 2007].
o VOI Consulting (2006) PharmaHandbook: A Guide to the International
Pharmaceutical Industry 2006.
51
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN CANADA 2006 Table No 1. Total Physicians by Specialty and Gender
SPECIALTY TOTAL MALE % FEMALE %
TOTAL PHYSICIANS 63,819 43,062 67 20,757 33
FAMILY PHYSICIANS 32,784 20,688 63 12,096 37 Family Medicine 15,832 8,447 53 7,385 47 General Practice 16,952 12,241 72 4,711 28
MEDICAL SPECIALISTS 22,742 15,629 69 7,113 31
Clinical Specialists 21,275 14,674 69 6,601 31 Anesthesiology 2,628 1,947 74 681 26
Community Medicine 419 253 60 166 40
Dermatology 526 323 61 203 39
Diagnostic Radiology 2,087 1,562 75 525 25
Emergency Medicine 541 439 81 102 19
Internal Medicine 6,922 5,080 73 1,842 27 Cardiology 1,025 871 85 154 15
Clinical Immunology/Allergy 141 102 72 39 28
Endocrinology/Metabolism 380 202 53 178 47 Gastroenterology 511 408 80 103 20
General Internal Medicine 2,440 1,918 79 522 21
Geriatric Medicine 211 105 50 106 50
Hematology 297 187 63 110 37
Infectious Diseases 200 118 59 82 41
Medical Oncology 364 226 62 138 38
Nephrology 464 316 68 148 32
Respiratory Medicine 568 437 77 131 23
Rheumatology 321 190 59 131 41
Medical Genetics 66 34 52 32 48
Neurology 743 577 78 166 22
Nuclear Medicine 233 191 82 42 18 Occupational Medicine 49 37 76 12 24
52
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN CANADA 2006 Table No 1. Total Physicians by Specialty and Gender (Cont…) SPECIALTY TOTAL MALE % FEMALE %
Pediatrics 2,209 1,147 52 1,062 48
Physical Medicine / Rehabilitation 369 258 70 111 30
Psychiatry 4,131 2,576 62 1,555 38 Radiation Oncology 352 250 71 102 29
Laboratory Specialists 1,467 955 65 512 35 Anatomical Pathology 747 449 60 298 40
General / Clinical Pathology 290 220 76 70 24
Hematological Pathology 62 39 63 23 37
Medical Biochemistry 89 69 78 20 22
Microbiology & Infectious Diseases 243 149 61 94 39
Neuropathology 36 29 81 7 19
Surgical Specialists 8,260 6,713 81 1,547 19 Cardiovascular / Thoracic Surgery 320 294 92 26 8
General Surgery 1,879 1,586 84 293 16
Neurosurgery 260 242 93 18 7 Obstetrics / Gynecology 1,694 979 58 715 42
Ophthalmology 1,114 902 81 212 19
Orthopedic Surgery 1,270 1,180 93 90 7
Otolaryngology 634 538 85 96 15
Plastic Surgery 493 428 87 65 13
Urology 596 564 95 32 5
Medical Scientists 33 32 97 1 3
Source: CMA (2007) Number and percent distribution of physicians by specialty and sex, Canada 2007 [internet], CMA. Available from: <http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Statistics/06SpecSex.pdf> [Accessed September 2007]
53
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN CANADA 2006 Table No 2. Total Physicians by Specialty and Age
SPECIALTY TOTAL UNDER 35 35-44 45-54 55-64 65 AND OVER UNKNOWN AGE
TOTAL PHYSICIANS 63,819 4,210 16,334 19,813 14,654 7,688 1,120
FAMILY PHYSICIANS 32,784 2,412 8,470 10,593 7,636 3,041 632 Family Medicine 15,832 1,995 6,227 4,796 2,328 463 23
General Practice 16,952 417 2,243 5,797 5,308 2,578 609
MEDICAL SPECIALISTS 22,742 1,346 5,643 6,962 5,249 3,180 362
Clinical Specialists 21,275 1,313 5,365 6,416 4,881 2,960 340 Anesthesiology 2,628 167 670 937 548 265 41
Community Medicine 419 17 78 149 131 41 3
Dermatology 526 15 117 154 144 89 7
Diagnostic Radiology 2,087 121 541 584 450 351 40
Emergency Medicine 541 51 187 177 108 11 7
Internal Medicine 6,922 559 1,960 1,901 1,485 886 131 Cardiology 1,025 44 310 329 247 83 12
Clinical immunology / Allergy 141 10 48 30 37 14 2
Endocrinology / Metabolism 380 35 122 109 64 41 9
Gastroenterology 511 52 144 146 111 48 10
General Internal Medicine 2,440 215 557 473 578 558 59
Geriatric Medicine 211 8 72 89 33 8 1
Hematology 297 22 80 107 56 23 9
Infectious Diseases 200 16 77 68 32 2 5
Medical Oncology 364 25 124 113 69 29 4
Nephrology 464 68 181 123 51 33 8 Respiratory Medicine 568 43 156 203 128 30 8
Rheumatology 321 21 89 111 79 17 4
Medical Genetics 66 4 18 17 17 8 2
Neurology 743 38 192 212 164 133 4
Nuclear Medicine 233 10 55 92 45 30 1
Occupational Medicine 49 0 10 10 27 1 1
54
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN CANADA 2006 Table No 2. Total Physicians by Specialty and Age (Cont…)
SPECIALTY TOTAL UNDER 35 35-44 45-54 55-64 65 AND OVER UNKNOWN AGE
Pediatrics 2,209 154 541 641 524 313 36
Physical Medicine / Rehabilitation 369 19 99 114 85 47 5
Psychiatry 4,131 137 790 1,304 1,093 759 48
Radiation Oncology 352 21 107 124 60 26 14
Laboratory Specialists 1,467 33 278 546 368 220 22 Anatomical Pathology 747 17 153 296 191 76 14
General / Clinical Pathology 290 4 49 89 63 84 1
Hematological Pathology 62 3 10 19 20 8 2
Medical Biochemistry 89 1 11 31 29 15 2
Microbiology & Infectious Diseases 243 8 48 97 56 32 2
Neuropathology 36 0 7 14 9 5 1
Surgical Specialists 8,260 452 2,221 2,258 1,760 1,443 126 Cardiovascular / Thoracic Surgery 320 11 93 87 78 47 4
General Surgery 1,879 108 504 472 381 386 28
Neurosurgery 260 11 84 62 54 43 6
Obstetrics/Gynecology 1,694 106 456 475 383 261 13
Ophthalmology 1,114 47 246 347 257 201 16
Orthopedic Surgery 1,270 69 364 352 257 197 31
Otolaryngology 634 42 168 156 126 130 12
Plastic Surgery 493 28 123 159 107 70 6
Urology 596 30 183 148 117 108 10
Medical Scientists 33 0 0 0 9 24 0
Source: CMA (2007) Number of physicians by specialty and age, Canada, 2007 [internet], CMA. Available from: <http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Statistics/02SpecAge.pdf> [Accessed September 2007]
55
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN CANADA 2006 Table No 3. Results from the National Physician Survey 2004 Questionnaire (work Setting)
GP/FP OR SPECIALIST SEX AGE GROUP ALL PHYSICIAN WORK SETTING GP/FP SPECIAL
ISTS MALE FEMALE NOT STATED <35 35-44 45-54 55-64 65+ NOT
KNOWN PHYSICI
ANS Number of respondents 11,041 10,255 13,454 6,885 957 1,829 5,294 6,622 4,461 2,066 1,024 21,296 Private office/clinic (excluding free standing walk-in clinics) 70.40% 50.10% 62.30% 59.00% 49.50% 58.00% 56.50% 62.20% 65.10% 64.10% 50.90% 60.70%
Community clinic / Community health centre 13.70% 6.40% 8.00% 14.60% 8.70% 16.00% 11.70% 10.50% 7.40% 6.50% 8.90% 10.20%
Free-standing walk-in clinic 14.40% 1.20% 8.00% 8.60% 4.90% 12.40% 9.60% 7.70% 6.50% 6.10% 5.40% 8.10%
Academic health sciences centre 11.20% 46.00% 27.90% 26.80% 37.30% 23.80% 28.70% 29.80% 27.70% 19.70% 37.30% 28.00%
Community hospital 39.30% 45.10% 44.40% 38.10% 39.70% 51.60% 46.20% 42.30% 38.40% 31.50% 40.20% 42.10% Emergency department (community hospital or academic health sciences)
23.50% 10.60% 18.40% 15.30% 16.70% 37.30% 23.00% 15.60% 10.50% 4.90% 17.70% 17.30%
Nursing home/Home for the aged 24.60% 2.20% 15.00% 12.20% 9.00% 13.80% 13.20% 15.10% 14.90% 11.10% 9.50% 13.80%
Administrative office 6.70% 6.30% 7.20% 5.00% 7.60% 2.20% 4.90% 8.70% 7.60% 4.50% 7.80% 6.50%
Research unit 1.70% 5.60% 4.20% 2.40% 3.80% 1.90% 4.40% 4.10% 3.30% 2.00% 4.10% 3.60% Free-standing laboratory/Diagnostic clinic 0.50% 2.80% 1.90% 1.10% 1.90% 0.80% 1.30% 1.80% 1.80% 2.30% 2.00% 1.60%
Other 11.30% 5.80% 7.80% 10.40% 7.80% 6.30% 8.70% 10.30% 7.80% 7.40% 7.80% 8.60%
No response 0.80% 0.60% 0.70% 0.50% 2.50% 0.50% 0.50% 0.60% 0.80% 1.40% 0.70% 0.70%
Note: Column totals exceed 100% as this question allowed for multiple responses. Source: National Physician Survey (2006) Q1 National Data Work settings by FP/Specialist, Sex, and Age Group [internet], National Physician Survey. Available from: <http://www.nationalphysiciansurvey.ca/nps/results/PDF-e/FP/Tables/National/Q01.pdf> [Accessed September 2007]
56
9. France
57
9.1. Introduction to France
France is divided into 26 administrative regions. 22 are in metropolitan France (21 are on
the continental part of metropolitan France; one is the territorial collectivity of Corsica),
and four are overseas regions. The regions are further subdivided into 100 departments
which are numbered (mainly alphabetically). This number is used in postal codes and
vehicle number plates amongst others. Four of these departments are found in the
overseas regions and are simultaneously overseas regions and overseas departments and
are an integral part of France (and the European Union) and thus enjoy a status similar to
metropolitan departments.
The 100 departments are subdivided into 341 arrondissements which are, in turn,
subdivided into 4,032 cantons. These cantons are then divided into 36,680 communes,
which are municipalities with an elected municipal council. There also exist 2,588
intercommunal entities grouping 33,414 of the 36,680 communes (i.e. 91.1% of all the
communes). Three communes, Paris, Lyon and Marseille are also subdivided into 45
municipal arrondissements (Figure 3).
58
Figure 3: A geographical map of France
Source: www.wikipedia.org D A T A M O N I T O R
The regions, departments and communes are all known as territorial collectivities,
meaning they possess local assemblies as well as an executive. Arrondissements and
cantons are merely administrative divisions. However, this was not always the case. Until
1940, the arrondissements were also territorial collectivities with an elected assembly, but
these were suspended by the Vichy regime and definitely abolished by the Fourth
Republic in 1946. Historically, the cantons were also territorial collectivities with their
elected assemblies.
59
In addition to the 26 regions and 100 departments, the French Republic also has six
overseas collectivities, one sui generis collectivity (New Caledonia), and one overseas
territory. Overseas collectivities and territories form part of the French Republic, but do
not form part of the European Union or its fiscal area. The Pacific territories continue to
use the Pacific franc whose value is linked to that of the euro. In contrast, the four
overseas regions used the French franc and now use the euro.
9.2. France’s healthcare system
The health care system is regulated by two main players; the state – the National
Assembly, the government and ministries – and the statutory health insurance funds. The
local communities play a relatively lesser role in regulating the system.
At the national level, the National Assembly has sought to improve the system with
annual Acts on Social Security Funding since 1996. It set the national ceiling for health
insurance spending. Recent changes have included improving insurance benefits for self-
employed people, setting up funds for the modernization of hospitals and developing
pharmaceutical information. Directorates in the Ministry of Health responsible for health
policy, hospital and health care, social security and financial matters and social policy.
The state exercises its trusteeship through central, regional and departmental services.
There are two large organizations that work under the Ministry of Health: General Health
Management and Hospital and Healthcare Management.
Under the direction of these two large organizations are numerous health care facilities
and agencies. The Ministry also has directorates of health and social affairs at the local
regional levels, such as the regional hospital agencies, the regional unions of the health
insurance funds and the regional unions of self-employed doctors. Figure 4 gives an
overview of the healthcare system in France.
60
Figure 4: The French healthcare system
Source: internal secondary research D A T A M O N I T O R
9.3. Healthcare insurance
The French population is almost universally covered (99% of the population) by statutory
health insurance (Assurance-Maladie), a branch of the social security system (Sécurité
Sociale). The national health insurance agency is the Caisse National d’Assurance
Maladie (National Fund for Sickness Insurance). Affiliation to Assurance-Maladie is by
means of different schemes, determined by the individual’s social and/or professional
category. The main scheme, the Régime Général, covers employees and pensioners from
trade and industry sectors, as well as their families and thus, accounts for approximately
80% of the French population. In addition, more than 80% of French people have
supplemental insurance with private insurers (Mutuelles) often provided by their
employers, which usually covers the cost of healthcare not otherwise covered by social
security insurance, such as the proportion of the cost of prescribed products normally
paid by the patient. According to figures from the OECD, private insurance accounted for
12.7% of total health expenditure in France in 2001.
61
Within the statutory health insurance system, patients have a free choice of general
practitioner and pharmacist, free access to specialists, and also a free choice amongst
public and private (approved) hospitals should they require hospitalization. There was in
the past no obligation on patients to present first to their GP in order to gain access to
specialists, unlike in the UK for example, and therefore GPs sometimes did not know
which drugs a specialist had prescribed, and vice versa, leaving the way open to drug
interactions. It was relatively common for “doctor-hopping” to occur, thus making it
difficult for doctors to have access to a patient’s complete medical history.
An agreement aimed at addressing this problem was finalized in 1998, after lengthy
negotiations, between the French general practitioners union, MG France, and the
national drug insurance agency, Caisse National d’Assurance Maladie (CNAM). This
agreement is based on the concept of the “gatekeeper GP” (médecin référent). Under this
scheme, patients can volunteer to register and stay with one GP, receiving in return
benefits such as dispensation from prior payment of the doctor’s fee. They also undertake
to consult the GP first rather than go directly to a specialist, other than in exceptional
circumstances, and if they do see a specialist they undertake to ensure that the médecin
référent is kept informed. In order to encourage GPs to participate in this scheme they are
offered a yearly allowance of $70 (€45.73) per registered patient. Participating doctors
agree to prescribe a certain percentage of generic products and they receive certain
“prescription supports”, involving the use of databases, particularly of pharmaceutical
products, prescribing guidelines and medico-economic information. It should be
emphasized, however, that participation in this médecin référent scheme is not obligatory
for either doctors or patients, and thus the problems of incomplete medical records and
“doctor-hopping” still continue.
62
9.4. Service delivery
Self-employed doctors, dentists and medical auxiliaries managed by local authorities and,
to a lesser extent, salaried staff in hospitals deliver primary and secondary health care. In
general, patients pay the provider and are subsequently reimbursed by their health
insurance fund. There is no gate keeping and patients have free choice of doctor.
In total, there are 3,171 healthcare establishments which offer 4,857,698 hospital beds for
long-term care and 45,727 beds for short-term care (Embassy of France in the United
States, http://www.info-france-usa.org/atoz/health.asp). Of the total number of hospitals
in France, 25% are public hospitals, 33% are private non-profit hospitals and 40% are
private for-profit hospitals (HiT summary, 2004).
Within the public hospital system, there are four levels: general, providing acute, follow-
up, rehabilitation and long-term care; regional, providing more highly specialized care
and teaching facilities; local, providing health and social care functions; and psychiatric.
Public and private hospitals provide different types of services. While the private sector is
focused on minor surgical procedures, the public and not-for-profit sector focuses more
on emergency admissions, rehabilitation, long-term care and psychiatric treatment. Day
surgery and “hospitalization at home” are being considered as alternative options.
According to the World Health Organization Regional Office for Europe, 1032 hospitals
(with 315,687 beds) which include regional, university, local and general hospitals fall
under the public hospital statute in 2006. Public hospitals include a diverse group of
institutions. For example, the Public Assistance Hospital of Paris employs over 80, 000
people while the smallest local hospital employs less than 300. Public hospitals constitute
65% of all inpatient beds in France (WHO regional office for Europe, 2004).
According to the World Health Organization Regional Office for Europe, there were
2139 private for profit and private not-for-profit healthcare facilities (with 170,382 beds)
in 2006. Private clinics were started by surgeons and obstetricians and eventually evolved
63
into private hospitals. Private for-profit hospitals constitute 20% of all inpatient beds in
France (WHO regional office for Europe, 2004). Not-for-profit private hospitals were
originally denominational and currently make up 14% of the inpatient services among
French Medical Care Institutions. They are financed through endowments like public
hospitals, but have the right to privacy like private clinics. About 15% of all inpatient
beds are provided by private not-for-profit hospitals (WHO regional office for Europe,
2004). The cooperation between the public and private sector in France produces a
healthcare system that is open to all, allows citizens to avoid waiting lists for surgeries,
and provides the latest in medical technology and treatment.
9.4.1. Public hospitals
Hospitals that fall under the public hospital statutes include regional, university, local and
general hospitals. Public hospitals are sometimes organized into groups, for example
those of the Assistance publique–Hôpitaux de Paris (Public Assistance Hospitals of
Paris), which employs over 80,000 people, while in comparison some small local
hospitals employ fewer than 300. Public hospitals provide approximately two-thirds of
the total number of hospital beds in France. In common with many countries, the trend is
towards a decrease in the number and duration of long-stay beds and an increase in the
number and duration of short-stay beds.
9.4.2. Private hospitals
Private hospitals were founded by surgeons and obstetricians, and originally each doctor
had absolute independence. However, a 1991 law now requires all doctors in private
clinics to share medical files with their colleagues, to create a Medical Care Commission
and to develop quality evaluation procedures. The use of private hospitals is relatively
common in France compared to the rest of Europe, and private hospitals often treat
patients referred from the public sector, which means that waiting lists are virtually
unknown in both the public and private sectors. Private hospitals are particularly active in
certain areas, treating more than 50% of surgical cases and 60% of cancer cases.
64
9.4.3. Not-for-profit hospitals
Not-for-profit establishments were originally denominational and currently make up
some 14% of the in-patient service amongst French medical care institutions. Healthcare
provision at the community level includes the following:
o office-based physicians (GPs or specialists);
o pharmacists;
o dentists;
o community nurses;
o ambulance services.
9.5. Healthcare financing and expenditure
The total expenditure on health care was 10.5% of gross domestic product (GDP) in
2004. In the same year, the total expenditure on health per capita was estimated at $3,
040. In 2004, 46.5% of the total health expenditure was spent on inpatient care, 26.1% on
outpatient care and 20.5% on drugs (HiT summary, 2004). Public expenditure constituted
78.4% of total health expenditure in 2004 while the private share amounted to 21.6%.
Out-of-pocket payments and supplementary private health insurance are both prevalent,
largely due to the number of services not covered by statutory health insurance and the
expense of co-payments. The following table (Table 7) shows the key health expenditure
indicators in 2004.
65
Table 7: French healthcare spending statistics
Indicator Value Total expenditure on health as percentage of GDP 10.5% (2004) Public expenditure on health as percentage of total expenditure on health 78.4% (2004) Private expenditure on health as percentage of total expenditure on health 21.6% (2004) Out-of-pocket expenditure as percentage of private expenditure on health 34.9% (2004) Private prepaid plans as percentage of private expenditure on health 57.3% (2004) Per capita total expenditure on health $3,040 (2004)
Source: WHO sources World Health Statistics D A T A M O N I T O R
9.6. Resources
There are approximately 1.6 million health care professionals in France, accounting for
6.2% of the working population. In 2005, there were 4 physicians and 7 nurses per 1,000
population (OECD Health data, 2007). The distribution of doctors shows geographical
disparities with more number of doctors in Paris and the south of France. The number of
acute care hospital beds in France was 3.7 per 1,000 population in 2005 (OECD Health
data, 2007). The following table gives the absolute number and density of physicians and
nurses in the recent years (Table 8).
Table 8: French physician and nurse numbers Resource indicator Value (year) Physicians (number) 203,487 (2004) Physicians (density per 1,000 population) 4 (2005) Nurses (number) 437,525 (2004) Nurses (density per 1,000 population) 7 (2005)
Source: OECD Healthcare Statistics, 2007 D A T A M O N I T O R
For a complete review of the most up to date physician statistics, please refer to the
French physician statistics section of this report.
66
9.7. The French pharmaceuticals market
The French pharmaceutical market totaled €21.9 billion ($27.2 billion) in 2005. This
represented a 5% increase in local currency terms. Per person consumption was €348
($454; internal secondary research). France is the second largest market in Europe (after
Germany) and the fourth largest in the world (after the US, Japan and Germany). In
France, 90% of physician visits include a prescription (compares with 83% in Spain, 72%
in Germany and 43% in the Netherlands). All but 6% of sales take place within the
reimbursement system - either in hospitals (19% of total market) or in pharmacies (75%
of total market; France: Healthcare and pharmaceuticals background, 2006). OTC
products (some of which are reimbursed) accounted for €1.6 billion in 2005, a decline of
3% over 2004 (Pharma Market Letter, March 2006). Within the prescription drug market,
generics have 8% of sales, off-patents brands have 17% and patented products have 75%
(Pharma Market Letter, February 2006). Table 9 shows retail sales for the leading
therapeutic categories.
Table 9: French retail sales by therapeutic category, 2005 Category Sales 2005 $m % change Cardiovascular 5,104 4% Central Nervous Sys 3,562 3% Alimentary & Metabolism 3,079 0% Respiratory 1,911 5% Anti- Infectives 1,962 9% Musculoskeletal 1,221 -1% Genitourinary 1,189 1% Cytostatics 1,284 19% Blood Agents 1,045 31% Dermatologicals 619 3% Sensory Organs 475 8% Diagnostic Agents 376 8% Systemic Hormones 397 9% Miscellaneous 102 3% Hospital Solutions 34 16% Parasitology 48 8% Total 22,408 11%
Source: internal secondary research D A T A M O N I T O R
67
The majority of sales take place within the reimbursement system - either in hospitals
(19% of total market) or in pharmacies (75% of total market). OTC products (some of
which are reimbursed) accounted for $2.38 billion in 2005. Within the prescription drug
market, generics make up 8% of sales, off-patents brands have 17% and patented
products have 75%.
Of the three largest EU markets (France, Germany, UK), France has the least industry-
favorable system. Prices are kept at very low levels, the launch of innovative products is
delayed by lengthy negotiations, the government forces substantial annual rebates from
manufacturers and promotional activities are taxed rather than counted as a business
expense. As shown in the table below, the government has launched a number of cost
control initiatives that work to the disadvantage of the research-based industry. The
following table (Table 10) shows the pharmaceutical reforms in 2005 and 2006.
68
Table 10: Pharmaceutical reforms in France, 2001-2006 Year Measure 2001 • Tax on promotional activities exceeding 14% of sales increased to 31% from
21%. • 15% price cut on innovative drugs. • 148 vasodilators removed from reimbursement lists
2002 • Physicians agree that 25% of prescriptions will be written generically, and that they will encourage patients to accept generic substitution.
Public awareness campaign launched to promote generic use. 2003 • Announcement of 617 products of “insufficient” effectiveness to be moved from
65% to 35% reimbursement. Will be phased in from 2003-05. • 82 products removed from reimbursement lists entirely. • Partial reference pricing system (TFR - tariff forfaitaire de responsabilité)
introduced for categories with generic options. Patients must pay difference between generic reimbursement rate and branded price.
• Tax raised on pharmaceutical promotional activity. 2004 • 426 products to be removed from reimbursement lists entirely.
• Target growth rate for drug reimbursement set at 3% (down from 4% in 2003). • Reimbursement on 29 vasodilators reduced to 35% from 65%.
2005 • Changes brought on by the Healthcare Reform: o Additional contribution equaling 0.6% of sales. o A 10% reduction in the price of existing generics. o Newly launched generics priced at 40% to 50% of original brand rather than
the previous 28%. o Possibility of increased control over marketing (details have not been
worked out at this writing). • Extension of the reference price groups (the TFRs - “Tarifs forfaitaires de
responsabilite”) by which off-patent brands are reimbursed at the price of generics. o TFR changes resulted in 30% average reduction on 18 product groups
• Cuts will be effective June 1, 2005 2006 • 15% price cut on products with generic equivalents.
• Removed 152 products of dubious efficacy from reimbursement lists (another round to follow).
• Turnover tax increased to 1.76% in 2006 from 0.6% (medical devices included for first time).
• Continuation of mandatory rebates for spending over the budgeted amount. • New tax on clinical research. • Incremental tax on products receiving marketing authorizations from 2005 to
2008. • Pharmacists to exercise rights of substitution on 70% of generic-eligible
prescriptions
Source: Datamonitor research D A T A M O N I T O R
69
The general system for obtaining drugs involved the patient paying for the drug, being
reimbursed by their health insurance fund and complementary VHI. Recently, the third
party payment system has become more common, involving direct payment to the
pharmacist by the health insurance fund. This system of payment applies to about two
thirds of drug purchases. About 60% of the total expenditure on drugs, covering both
prescribed drugs and products purchased over the counter, is publicly funded; the
remainder is financed, in equal proportion (18.5%), by private households and
complementary VHI.
The pharmacy reimbursement system for multi-source categories (i.e. where a generic
option is available) was changed to provide 2.5% margin on branded products and 10%
on generics. In March 2006, the substitution rate (i.e. the percentage of generic-eligible
prescriptions to be filled with generics) was 66.4% up from 61.6% in December 2005.
The average price for a generic prescription in 2005 was $4.78, which is 35% lower than
the European average of $7.3. Financial sustainability, the ageing population, increasing
health care expenditure, the need for rationing and a decreasing supply of doctors are
some challenges that need to be addressed.
70
9.8. Bibliography
o World Health Organization (2004) Health systems in transition 2004 [Internet],
WHO Regional Office for Europe on behalf of the European Observatory on
Health Systems and Policies. Available from:
<http://www.euro.who.int/document/e83126.pdf> [Accessed October 2007].
o World Health Organization (2007) World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=fra&indicators=selected&language=en> [Accessed October 2007].
o World Health Organization (2007) World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=fra&indicators=healthpersonnel> [Accessed October 2007].
o OECD data (2007) OECD Health data 2007 [Internet]. Available from: <
http://www.oecd.org/dataoecd/45/20/38980771.pdf> [Accessed October 2007].
o VOI Consulting (2006) PharmaHandbook: A Guide to the International
Pharmaceutical Industry 2006.
o Embassy of France in the United States (2005) [Internet], Available from:
<http://www.info-france-usa.org/atoz/health.asp> [Accessed October 2007].
o Datamonitor (2004), Exploiting technology opportunities in European healthcare,
2004, DMTC1017.
71
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN FRANCE 2006 Table No 1. Total Physicians by Specialty and Gender SPECIALTY TOTAL MALE % FEMALE %
TOTAL PHYSICIANS 198,215 122,557 62 75,658 38 Anatomy and Cytopathology 1,463 578 40 885 60 Anesthesiology 9,577 6,266 65 3,311 35 Cardiology 5,952 4,879 82 1,073 18 Child and Adolescent Psychiatry 1,232 597 48 635 52 Dermatology and Venereology 3,821 1,401 37 2,420 63 Digestive Surgery 642 570 89 72 11 Endocrinology and Metabolism 1,483 447 30 1,036 70 Gastroenterology 3,266 2,515 77 751 23
General Medicine1 96,717 59,765 145 36,952 55 General Surgery 3,699 3,398 92 301 8 Geriatrics 341 158 46 183 54 Gynecology and Obstetrics (Surgery) 3,120 2,145 69 975 31 Gynecology and Obstetrics2 2,119 2,099 2,112 2,118 2,182 Hematological Oncology 14 9 64 5 36 Hematology 235 114 49 121 51 Internal Medicine 2,373 1,683 71 690 29 Maxillofacial surgery 63 46 73 17 27 Medical Biology 2,587 1,300 50 1,287 50 Medical Genetics 182 58 32 124 68 Medical Oncology 587 331 56 256 44 Medical Rehabilitation 54 48 89 6 11 Medical Research 14 8 57 6 43 Nephrology 1,186 802 68 384 32 Neurology 1,799 1,091 61 708 39 Neurosurgery 382 343 90 39 10
Nuclear Medicine 521 349 67 172 33 Occupational Medicine 6,049 1,803 30 4,246 70 Ophthalmology 5,374 3,099 58 2,275 42
72
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN FRANCE 2006 Table No 1. Total Physicians by Specialty and Gender (Cont…) SPECIALTY TOTAL MALE % FEMALE %
Orthopedic Surgery 2,483 2,400 97 83 3
Otolaryngology 2,861 2,383 83 478 17 Pediatric Surgery 211 142 67 69 33 Pediatrics 6,441 2,555 40 3,886 60 Physical Medicine and Rehabilitation 1,761 1,027 58 734 42 Plastic, Cosmetic and Reconstructive Surgery 688 556 81 132 19 Pneumology 2,556 1,727 68 829 32 Psychiatry3 11,658 6,571 131 5,087 69 Public Health 1,556 653 42 903 58
Radiology and Medical Imaging 7,142 5,091 71 2,051 29 Radiology, Medical Imaging and Radiotherapy 142 129 91 13 9 Radiotherapy 648 413 64 235 36 Rheumatology 2,503 1,574 63 929 37 Stomatology 1,204 1,015 84 189 16 Surgery of the Face and the Neck 2 2 100 0 0 Thoracic and Cardiovascular Surgery 250 240 96 10 4 Urologic Surgery 814 790 97 24 3 Vascular Surgery 443 420 95 23 5 1 General Medicine+General Medicine (Specialists) (General Medicine as a specialty was started in 2004) 2 Gynecology and Obstetrics+Medical Gynecology 3 Psychiatry+Neuropsychiatry Note: Data includes physicians in France and its overseas territories of Départements d'outre-mer (DOM) & Territoires d'outre mer (TOM) Source: Conseil National de l'Ordre des Médecins (2007) L’ATLAS DE LA DÉMOGRAPHIE MEDICALE EN France [internet], Conseil National de l'Ordre des Médecins. Available from: <http://www.web.ordre.medecin.fr/demographie/introatlas2007.pdf> [Accessed September 2007]
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PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN FRANCE 2006 Table No 2. Total Physicians by Specialty and Age
SPECIALTY TOTAL <40 40-44 45-49 50-54 55-59 60-64 65 AND OVER
TOTAL PHYSICIANS 199,490 30,861 26,436 38,807 42,283 39,684 16,212 5,207 Anatomy and Cytopathology 1,471 250 247 249 357 226 113 29 Anesthesiology 10,235 758 939 2,264 2,244 1,408 953 1,669
Cardiology 5,966 1,066 858 1,129 1,135 1,059 565 154 Child and Adolescent Psychiatry 1,235 10 9 156 450 440 149 21 Dermatology and Venereology 3,825 449 464 781 928 792 337 74
Digestive Surgery 644 111 207 164 57 66 34 5 Endocrinology and Metabolism 1,487 418 296 274 262 173 49 15 Gastroenterology 3,269 631 528 723 587 529 224 47
General Medicine1 97,012 14,696 13,510 20,110 20,425 19,892 6,939 1,440 General Surgery 3,719 790 227 440 699 866 565 132 Geriatrics 341 45 70 83 70 53 16 4
Gynecology and Obstetrics (Surgery) 3,132 751 483 618 522 436 271 51 Gynecology and Obstetrics2 2,122 7 28 399 720 676 239 53 Hematological Oncology 10 3 3 3 0 1 0 0
Hematology 235 130 91 12 1 1 0 0 Internal Medicine 2,391 436 286 270 408 569 330 92 Maxillofacial surgery 64 48 14 2 0 0 0 0
Medical Biology 2,595 604 702 634 269 229 103 54 Medical Genetics 183 46 30 38 32 25 8 4 Medical Oncology 592 173 133 89 73 80 34 10
Medical Rehabilitation 54 17 15 13 5 2 1 1 Medical Research 15 0 2 13 0 0 0 0 Nephrology 1,190 298 200 207 187 201 83 14
Neurology 1,811 510 353 326 289 240 83 10 Neurosurgery 384 95 62 70 47 52 45 13 Nuclear Medicine 521 122 70 91 80 89 48 21
Occupational Medicine 6,052 617 516 828 1,834 1,816 375 66
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PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN FRANCE 2006 Table No 2. Total Physicians by Specialty and Age (Cont…)
SPECIALTY TOTAL <40 40-44 45-49 50-54 55-59 60-64 65 AND OVER
Ophthalmology 5,383 608 477 1,064 1,458 1,130 505 141 Orthopedic Surgery 2,493 458 500 603 406 327 156 43 Otolaryngology 2,864 357 349 527 698 584 292 57
Pediatric Surgery 211 54 48 34 35 24 13 3 Pediatrics 6,464 1,283 725 1,060 1,242 1,301 679 174 Physical Medicine and Rehabilitation 1,765 239 180 279 457 431 151 28
Plastic, Cosmetic and Reconstructive Surgery 690 130 160 148 101 72 65 14 Pneumology 2,560 516 381 472 566 431 165 29 Psychiatry3 11,737 1,771 1,387 1,685 2,477 2,637 1,333 447
Public Health 1,582 320 125 328 375 338 91 5 Radiology and Medical Imaging 7,162 1,198 957 1,466 1,465 1,365 633 78 Radiology, Medical Imaging and Radiotherapy 142 0 0 4 4 8 42 84
Radiotherapy 650 140 85 107 139 119 50 10 Rheumatology 2,508 355 330 511 522 506 235 49 Stomatology 1,208 32 52 233 421 280 137 53
Surgery of the Face and the Neck 2 2 Thoracic and Cardiovascular Surgery 253 55 86 69 20 17 6 0 Urologic Surgery 815 198 187 157 113 97 56 7
Vascular Surgery 446 64 64 74 103 96 39 6 1 General medicine+General Medicine (Specialists) (General Medicine as a specialty was started in 2004) 2 Gynecology and Obstetrics+Medical Gynecology 3 Psychiatry+Neuropsychiatry Note:
1) Data also includes overseas French physicians and who are not practicing in France. So the total number of physicians does not match with that of in table 1 & table 3. 2) Data includes physicians in France and its overseas territories of Départements d'outre-mer (DOM) & Territoires d'outre mer (TOM)
Source: Conseil National de l'Ordre des Médecins (2007) L’ATLAS DE LA DÉMOGRAPHIE MEDICALE EN France [internet], Conseil National de l'Ordre des Médecins. Available from: <http://www.web.ordre.medecin.fr/demographie/introatlas2007.pdf> [Accessed September 2007]
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PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN FRANCE 2006 Table No 3. Total Physicians by specialty and Major Professional Activity
MAJOR PROFESSIONAL ACTIVITY
PATIENT CARE INCOME SPECIALTY TOTAL TOTAL
PATIENT CARE
OFFICE BASED
HOSPITAL BASED
MIXED/ OTHERS FEES SALARIED
TOTAL PHYSICIANS 198,215 198,215 123,612 72,855 1,748 108,947 89,268 Anatomy and Cytopathology 1,463 1,463 616 839 8 704 759 Anesthesiology 9,577 9,577 3,076 6,485 16 3,201 6,376 Cardiology 5,952 5,952 2,784 3,132 36 3,591 2,361 Child and Adolescent Psychiatry 1,232 1,232 555 673 4 440 792 Dermatology and Venereology 3,821 3,821 2,654 1,140 27 2,975 846
Digestive Surgery 642 642 252 390 0 293 349 Endocrinology and Metabolism 1,483 1,483 544 922 17 707 776 Gastroenterology 3,266 3,266 1,365 1,890 11 1,783 1,483 General Medicine1 96,717 96,717 75,322 20,068 1,327 62,735 33,982 General Surgery 3,699 3,699 1,226 2,465 8 1,444 2,255 Geriatrics 341 341 64 277 0 19 322 Gynecology and Obstetrics (Surgery) 3,120 3,120 1,092 2,028 0 1,362 1,758 Gynecology and Obstetrics2 2,119 2,119 1,265 850 4 1,556 563
Hematological Oncology 14 14 2 12 0 1 13 Hematology 235 235 13 219 3 14 221 Internal Medicine 2,373 2,373 285 2,065 23 341 2,032 Maxillofacial surgery 63 63 34 29 0 40 23 Medical Biology 2,587 2,587 1,428 1,116 43 1,090 1,497 Medical Genetics 182 182 17 163 2 8 174 Medical Oncology 587 587 116 466 5 134 453 Medical Rehabilitation 54 54 1 53 0 1 53
Medical Research 14 14 4 7 3 3 11 Nephrology 1,186 1,186 285 896 5 267 919 Neurology 1,799 1,799 483 1,306 10 694 1,105 Neurosurgery 382 382 79 302 1 94 288
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PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN FRANCE 2006 Table No 3. Total Physicians by specialty and Major Professional Activity (Cont…)
MAJOR PROFESSIONAL ACTIVITY PATIENT CARE INCOME SPECIALTY TOTAL
TOTAL PATIENT CARE OFFICE BASED HOSPITAL
BASED MIXED/ OTHERS FEES SALARIED
Nuclear Medicine 521 521 161 358 2 154 367 Occupational Medicine 6,049 6,049 5,648 392 9 46 6,003 Ophthalmology 5,374 5,374 3,535 1,826 13 4,308 1,066 Orthopedic Surgery 2,483 2,483 1,168 1,312 3 1,381 1,102 Otolaryngology 2,861 2,861 1,544 1,309 8 1,996 865 Pediatric Surgery 211 211 23 188 0 29 182 Pediatrics 6,441 6,441 2,712 3,691 38 2,299 4,142 Physical Medicine and Rehabilitation 1,761 1,761 794 959 8 497 1,264
Plastic, Cosmetic and Reconstructive Surgery 688 688 441 247 0 569 119 Pneumology 2,556 2,556 797 1,742 17 964 1,592 Psychiatry3 11,658 11,658 4,839 6,790 29 4,647 7,011 Public Health 1,556 1,556 1,000 520 36 59 1,497 Radiology and Medical Imaging 7,142 7,142 4,124 3,011 7 4,626 2,516 Radiology, Medical Imaging and Radiotherapy 142 142 94 46 2 104 38 Radiotherapy 648 648 236 412 0 280 368 Rheumatology 2,503 2,503 1,402 1,080 21 1,632 871
Stomatology 1,204 1,204 797 405 2 979 225
Surgery of the Face and the Neck 2 2 0 2 0 0 2 Thoracic and Cardiovascular Surgery 250 250 71 179 0 89 161 Urologic Surgery 814 814 442 372 0 530 284 Vascular Surgery 443 443 222 221 0 261 182 1 General Medicine+General Medicine (Specialists) (General Medicine as a specialty was started in 2004) 2 Gynecology and Obstetrics+Medical Gynecology 3 Psychiatry+Neuropsychiatry Note: Data includes physicians in France and its overseas territories of Départements d'outre-mer (DOM) & Territoires d'outre mer (TOM) Source: Conseil National de l'Ordre des Médecins (2007) L’ATLAS DE LA DÉMOGRAPHIE MEDICALE EN France [internet], Conseil National de l'Ordre des Médecins. Available from: <http://www.web.ordre.medecin.fr/demographie/introatlas2007.pdf> [Accessed September 2007]
77
10. GERMANY
78
10.1. Introduction to Germany
With over 82 million inhabitants, Germany is the most populous country in the European
Union. However, its fertility rate of 1.39 children per mother is one of the lowest in the
world, and the federal statistics office estimates the population will shrink to between 69
and 74 million by 2050 (69 million assuming a net migration of +100,000 per year; 74
million assuming a net migration of +200,000 per year). Germany has a number of larger
cities, the most populous being Berlin, Hamburg, Munich, Cologne, Frankfurt and
Stuttgart.
As of December 2004, about seven million foreign citizens were registered in Germany,
and 19% of the country's residents were of foreign or partially foreign descent. The
largest group (2.3 million) is from Turkey, and a majority of the rest are from European
states such as Italy, Serbia, Greece, Poland, and Croatia. In its State of World Population
2006 report, the United Nations Population Fund lists Germany as hosting the third-
highest percentage of international migrants worldwide, about 5% or 10 million of all 191
million migrants. As a consequence of restrictions of Germany's formerly rather
unrestricted laws on asylum and immigration, the number of immigrants seeking asylum
or claiming German ethnicity (mostly from the former Soviet Union) has been declining
steadily since 2000. Immigrants to Germany often face integration issues among other
difficulties.
Germany has the second largest population in Europe (after European Russia) and is
seventh largest in area. The territory of Germany covers 357,021 km² (137,847 square
miles), consisting of 349,223 km² (134,836 square miles) of land and 7,798 km² (3,011
square miles) of water. Elevation ranges from the mountains of the Alps (highest point:
the Zugspitze at 2,962 metres (9,718 ft)) in the south to the shores of the North Sea
(Nordsee) in the north-west and the Baltic Sea (Ostsee) in the north-east. Between lie the
forested uplands of central Germany and the low-lying lands of northern Germany
(lowest point: Wilstermarsch at 3.54 metres (11.6 ft) below sea level), traversed by some
of Europe's major rivers such as the Rhine, Danube and Elbe. Because of its central
79
location, Germany shares borders with more European countries than any other country
on the continent. Its neighbors are Denmark in the north, Poland and the Czech Republic
in the east, Austria and Switzerland in the south, France and Luxembourg in the south-
west and Belgium and the Netherlands in the north-west. Germany is divided into sixteen
states (Länder, singular Land; commonly Bundesländer, singular Bundesland). It is
further subdivided into 439 districts (keise, singular Kreis) and cities (kreisfreie Städte)
(Figure 5).
Figure 5: Map of Germany showing states and key cities
Source: www.wikipedia.org D A T A M O N I T O R
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10.2. Germany’s healthcare system
Under the German constitution (Basic Law), the Federal Ministry of Health and the 16
Länder governments share decision-making responsibilities for healthcare provision,
while non-government, non-profit-making bodies play a vital role in financing and
delivering healthcare. Germany’s healthcare system traces its roots back to 1876 with the
establishment of the Health Office and subsequent setting up of the Statutory Health
Insurance (SHI) scheme by Chancellor Bismark in 1883. The minimum benefits covered
by the SHI defined by Bismark have expanded over the last century to represent a
comprehensive system of healthcare provision. A top-line structure of the German
healthcare system is given in Figure 6.
Figure 6: Structure of the German healthcare system
Source: internal secondary research D A T A M O N I T O R
The system is based on the principle of solidarity among the insured population who pay
contributions to sickness funds which are unrelated to the insured risks and who are
provided healthcare benefits that are not dependent on the amount of contributions. Some
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89% of Germany’s 82.5 million population are covered by the statutory health insurance
scheme, according to the European Observatory on Health Care Systems. Around 9% are
covered by private health insurance, 2% of the population are entitled to free government
healthcare (including police officers, soldiers and those doing an alternative to military
service, and individuals receiving social welfare). Less than 0.2% are uninsured.
10.3. Healthcare insurance
In the private sector, research has shown that some 7.7 million people were fully covered
by private health insurance in 2002, with a further 7.6 million people having
supplementary private cover, according to the association of private health insurers, PKV.
The 9.3% of the population who have full-cover private insurance include high-earning
employees who can opt out of the SHI, the self-employed and civil servants. Since the
government reimburses 50-80% of civil servants’ healthcare costs directly, private
insurance is often used to cover the portion not paid for by the government.
The 7.6 million SHI-insured people who take out private health insurance in general seek
to augment their state benefits, such as receiving treatment in single bed hospital rooms.
Unlike the system in France, where complementary insurance is taken out to cover co-
payments, German private insurance is regarded as a luxury choice. Some private
insurers have, however, begun to offer plans which cover SHI co-payments. According to
the German Federal Statistical Office, households with private insurance spend some 2.5
times more on out-of-pocket payments than those covered by the SHI. Policies and
premiums vary widely among private insurers. Since separate premiums are required for
dependants (unlike the SHI), private insurance tends to be favored among single people
or working couples. Group insurance is not a feature of the private market. The following
figure (Figure 7) shows the coverage of the patient population by insurance type in 2003.
82
Figure 7: German healthcare insurance coverage by type, 2003
Source: Datamonitor D A T A M O N I T O R
10.4. Service delivery
Public health is mainly the competence of the Länder. However, 14 out of 16 Länder
have devolved public health functions to municipalities. Public health offices are
responsible for surveillance and health reporting, for the supervision of environmental
and infectious hygiene of health care personnel and institutions in inpatient and outpatient
care. They are restricted to delivering a limited scope of preventive services, since most
preventive services, e.g. immunization, are provided by ambulatory physicians.
In terms of the Statutory Health Insurance System, the Social Code Book requires all
employees and certain defined groups (pensioners, students, artists and the disabled) to be
insured under the Statutory Health Insurance Scheme (Gesetzliche Krankenversicherung
– GKV). Membership of a statutory health insurance fund/sickness fund (Krankenkasse)
is compulsory for employees, except those whose income exceeds a specific level and
those who belong to a specific statutory scheme, such as civil servants. Contributions are
shared equally between employers and employees.
83
Some 75% of the population have compulsory SHI cover, while a further 14% are
covered voluntarily, according to Berlin-based healthcare expert Professor Dr Reinhard
Busse. Insured individuals are free to join any sickness fund and are also free to choose
their healthcare provider. The system is self-regulating, with the Social Code Book
providing the regulatory framework. The sickness funds and providers have delegated
regulatory powers and through their respective federal and regional associations
(corporatist bodies) exert legal power over their membership. While these bodies are not
private enterprises, they combine private status with public functions. Supervisory
oversight of the self-regulatory bodies is provided at federal and state levels.
The functions of payers and providers are separated, with sickness funds (payers)
negotiating healthcare services with providers on behalf of their members. Services
covered by contracts with providers are accessible to members without prior permission.
Insured patients make a contribution to the cost of healthcare services they receive
generally through a system of co-payments.
The sickness funds are responsible for collecting contributions from members and
determining premiums, within the limitations of the law. Since benefits provided by
sickness funds are essentially identical in terms of obligatory treatment, funds compete on
contribution rates to attract members. Expenditure has traditionally exceeded income,
prompting sick funds to implement cost-containment measures with the drug bill a target
for generating savings.
The providers are represented by the doctors’ and dentists’ associations who contract
with sickness funds to deliver healthcare services defined by law. Benefits covered by the
SHI are defined in general terms in the SHI benefits catalogue, which serves as the fee-
schedule for office-based physicians. Decisions on which benefits to exclude are made by
the Federal Committee of Physicians and Sickness Funds. Items which have been
excluded include technologies of limited medical benefit such as osteodensitometry for
asymptomatic patients, certain dental services, some medical aid devices, medicines for
84
minor illnesses such as the common cold and for travel-related diseases, and
pharmaceuticals which are of unproven medical benefit.
Negotiations between sickness funds and provider associations determine the financing
mechanisms and details of ambulatory care. The introduction of competition among
funds in 1996 saw a shift in negotiating contracts from a group or collective basis to
selective purchasing. Patients receive care free at the point of delivery as sick funds pay
providers for care delivered. An exception to this is the option of cost-reimbursement for
patients who are voluntarily insured under SHI. Healthcare provision is segregated
between ambulatory care, which is a powerful and growing sector, and hospitals, which
concentrate on inpatient care.
10.4.1. Ambulatory care
Office-based physicians provide virtually all ambulatory care, including primary and
outpatient secondary care. Since there is no gate keeping system patients are free to
choose a family practitioner affiliated to their sickness fund, although they cannot switch
doctors more frequently than quarterly. The large proportion of office-based specialists
also means that patients frequently seek specialist care in the ambulatory sector.
Ambulatory care physicians are legally responsible for providing preventive services,
including screening and check-ups, whereas immunization programs are negotiated with
sickness funds, hence the relatively low rates compared with international coverage. The
payment of office-based physicians for services they provide per patient encourages them
to see as many patients as possible.
The majority of office-based physicians refer their patients to hospital physicians for
inpatient treatment but carry out follow-up procedures themselves. Thus, patients
commonly receive post-surgical care from their primary care physician rather than the
hospital surgeon. In addition to office-based physicians, some 11,000 physicians
(generally heads of hospital departments) are accredited to treat ambulatory patients: they
85
are permitted to offer certain services and treat patients when physicians’ offices are
closed.
10.4.2. Hospital care
Due to a significant proportion of outpatient care provided by office-based physicians,
hospital care in Germany has focused on inpatient care. Formal outpatient facilities have
until recently been confined to university hospitals, although the growth in day surgery
and provision of specialized care, such as chemotherapy, on an outpatient basis has
changed the traditional basis of the sector. By the end of the 1990s, over half of German
hospitals offered ambulatory care.
A small percentage of office-based physicians (5%, according to the European
Observatory) are permitted to treat patients in the hospital setting. This usually applies to
less common surgical specialties where there is insufficient demand for a full-time
hospital specialist. Hospitals contract on an individual basis with sickness funds although
the services offered and remuneration rates are valid for all sickness funds. In general,
sickness funds with at least 5% market share in a particular hospital tend to negotiate the
contract with that hospital.
Referral from an ambulatory physician is required for access to German hospitals, with
the exception of emergency patients. Hospitals are required to accept all urgent cases
(which in Germany tends to cover a wide definition), regardless of occupancy rates.
Although patients are free to choose their hospital, the referring physician plays an
influencing role. The hospital’s ownership status is not relevant for insured patients.
Generally hospital admissions occur on the same day as the referral: waiting lists are not
an issue in Germany.
The German healthcare system is highly decentralized, although there are movements
towards adopting a more centralized approach by increasing the level of national
involvement. Sickness funds are the key stakeholder in terms of healthcare provision,
86
however other bodies and associations impact healthcare provision, as detailed in the
following figure (Figure 8).
Figure 8: A number of governmental bodies, physician and pharmacist associations, and industry associations impact healthcare provision in Germany
Source: internal secondary research
10.5. Healthcare financing and expenditure
Total health spending accounted for 10.7% of GDP in Germany in 2005. Germany ranks
only 10th among OECD countries in health spending per capita, with spending of $3,287
per person in 2005 (adjusted for purchasing power parity). Health spending per capita in
Germany increased, in real terms, by 1.3% per year on average between 2000 and 2005.
The relatively slow growth in health spending in Germany is partly due to cost-
containment measures that have been introduced in the context of health reforms.
Spending on pharmaceuticals in Germany has increased over the past decade and
accounted for 15.2% of total health expenditure in 2005. In 2005, 76.9% of health
spending in Germany was funded by public sources. The following table (Table 11)
shows the recent key health expenditure indicators.
87
Table 11: German healthcare spending statistics
Indicator Value Total expenditure on health as percentage of gross domestic product 10.7% (2005) Public expenditure on health as percentage of total expenditure on health 76.9% (2005) Private expenditure on health as percentage of total expenditure on health 23.1% (2005) Out-of-pocket expenditure as percentage of private expenditure on health 57.5% (2004) Private prepaid plans as percentage of private expenditure on health 39.1% (2004) Per capita total expenditure on health (adjusted for purchasing power parity) %3,287 (2005)
Source: WHO sources World Health Statistics, various years were used (see
above) D A T A M O N I T O R
Of the total expenditure, 57% of the funds came from statutory health insurance, 7% from
statutory long-term care insurance, 4% from other statutory insurance schemes and 8%
from government sources (World Health Organisation Regional Office for Europe, 2004).
Private health insurers financed 8%, employers 4% and non-profit organizations and
households 12% (World Health Organisation Regional Office for Europe, 2004). German
statutory insurance does not provide universal coverage – those with incomes above a
certain limit can choose to opt out in favor of private insurance. Approximately 9% of
Germany’s total healthcare expenditure comes from private insurance, while 10% comes
from out-of-pocket payments. Most out-of-pocket payments went to purchase over-the-
counter drugs and to co-payments for prescribed drugs. Co-payments were introduced in
2004, for outpatient visits and were raised for virtually all other benefits.
10.6. Resources
There are 4.2 million working in the German health sector, which accounted for 10.6% of
total employment at the end of 2002. There are more than 1 million employees working
in the German hospital sector. Since the early 1990s the total number of employees has
dropped by about 3.6% (Liberalisation, privatization and regulation in the German
healthcare sector/hospitals, 2006, Pique report).
88
Germany has more physicians and nurses than the average across OECD countries. In
2005, Germany had 3.4 practicing physicians per 1 000 population. Germany has 9.7
nurses per 1,000 population. The number of acute care hospital beds in Germany stood at
6.4 per 1,000 population in 2005. Although the number of hospital beds per capita and
average length of stay in acute hospitals in Germany has fallen over time, it still ranks
high on these indicators among the OECD countries. The following table (Table 12)
gives the total number of physicians and nurses as well as density per 1,000 population in
the recent years.
Table 12: German physician and nurse numbers
Resource indicator Value (year) Physicians (number) 277, 885 (2003) Physicians (density per 1,000 population) 3.4 (2005) Nurses (number) 801, 677 (2003) Nurses (density per 1,000 population) 9.7 (2005)
Source: OECD Healthcare Statistics, various years are indicated D A T A M O N I T O R
For a complete review of the most up to date physician statistics, please refer to the
German physician statistics section of this report. There were 2,166 hospitals with more
than 530, 000 beds in 2004. Since the 1990s the hospital capacities in Germany have
shown a continuous decline. Between 1991 and 2004, the total numbers of hospitals fell
by about 10% while the number of beds decreased by about 20%. The table below (Table
13) shows a comparison of German hospital key figures between 1991 and 2004
(Liberalisation, privatization and regulation in the German healthcare sector/hospitals,
2006, Pique report).
89
Table 13: The German Hospital sector – Key figures 1991 and 2004
1991 2004 Changes
1991/2004 Number of hospitals 2, 411 2, 166 -10.2% Number of beds 665, 565 531, 333 -20.2% Beds per 1,000 inhabitants 8.3 6.4 -22.9% Number of employees Total 1, 119, 791 1, 079, 831 -3.6% Full-time equivalents 875, 816 805, 988 -8.0% Hospital cases 14, 577, 000 16, 801, 000 15.3% Average length of stay 14.0 days 8.7 days -37.9% Average occupancy rate 84.10% 75.70% -10.0% Occupancy and billing days 204, 204, 000 146, 746, 000 -28.2%
Source: Liberalisation, privatization and regulation in the German healthcare
sector/hospitals, 2006, Pique report D A T A M O N I T O R
10.7. The German pharmaceuticals market
The pharmaceutical industry in Germany is among the most powerful in developed
countries and contributes significantly to the export market. There were about 1,100
pharmaceutical companies with 114,800 workers operating in Germany in 2002. Of the
pharmaceutical industry's total turnover of $34.6 billion in 2002, $17.0 billion was gained
in the domestic market and $17.6 billion from exports (especially the other European
Union countries, Japan, Switzerland and the United States).
Of the $54.6 billion spent on drugs in 2002, $46.8 billion was spent on pharmacies in
ambulatory care while $4.4 billion was spent on acute hospital care. Of the $49.6 billion
spent on drugs in pharmacies in 2002, $43.2 billion was spent on prescription drugs and
$6.2 billion on over-the-counter (OTC) medication. Expenditure on OTC drugs increased
until 1997 and has decreased since, while prescription drug costs rose continuously.
Private households spent about 25% of their out-of-pocket payments on drugs in 2001.
90
Of the total pharmaceutical expenditure in 2002, 70% was spent by statutory health
insurance, 6% by private health insurance, 18% by private households (and not-for profit
organizations), and the remaining 5% by other sources. Most pharmaceutical
expenditures were in ambulatory care. As a result of cost-sharing measures, private
household expenditures on pharmaceuticals increased throughout the 1990s, accounting
for up to 26% of pharmaceutical expenditures in 1998 but decreased again to 18% in
2002.
High R&D expenditures over the past few years made it possible to launch 23 new
molecular entities (NMEs) in the German market in 2005, most of which focused on
innovative therapeutic drugs for cancer. According to a Verband Forschender
Arzneimittelhersteller (VFA) report, Germany's share in the world market has decreased
from 5.2% in 1998 to 3.2%in 2005 (at a constant exchange rate). In Germany, innovative
pharmaceuticals are still prescribed less frequently than in other European countries, per-
capita sales are in the middle range in Europe, and the pharmaceutical market exhibits
only below-average growth in an international comparison. With a volume of about $26
billion in 2005, Germany is the third largest market for pharmaceuticals and yet, it is one
of the markets exhibiting below-average growth because of the high regulatory density.
From 1998 to 2005, sales in the German pharmacy market increased by about 40%.
In 2005, German pharmaceutical companies provided pharmaceuticals worth USD 32.6
billion (at manufacturers' prices) via pharmacies for outpatient treatment. A total of 15%
of this amount was for self-medication with over-the-counter (OTC) drugs, about 12% for
private prescriptions outside of statutory health insurance, and 73% for SHI prescriptions.
The latter category was financed through co-payments by insured patients, manufacturers'
and trade discounts and expenditures of the health insurance funds (86%).
In 2005, the gross sales volume in the German pharmacy market was USD 32.6 billion at
manufacturers' prices. Taking into account the rebates the manufacturers had to grant to
statutory health insurance (2004: USD 2.4 billion, 2005: USD 0.82 billion), these sales
decreased to USD 31.7 billion. About 81% of sales were made in prescription drugs. The
91
number of packages sold in 2005 was 1.62 billion, up 1.4% compared to the previous
year but down 4.9% compared to 2003.
In Germany, 75% of SHI prescriptions and at 49% almost half of all sales in the entire
market are generated in this so-called generics-eligible market. During the past 12 years,
Germany has evolved into the world's most generics-friendly country. Frequently, after
their patents expire, the original products lose almost their entire market share to generic
drugs within a few months. On average, 74% of all prescriptions and 70% of sales in the
generics-eligible market were generated by generics in 2004.
Much change has occurred in the German pharmaceutical market in recent years, with
sweeping healthcare reforms playing a critical role in pharmaceutical sales and research
and development. The leading reform principles after reunification have been to reduce
structural east-west differences and to contain costs through expenditure control,
prospective provider payment and regulated competition among sickness funds, while
securing quality and avoiding adverse effects on equity. Rationalization was given
priority over rationing. While cost-sharing was enhanced, few benefits were excluded
until 2004. At the same time, new benefits and separate mandatory long-term care
insurance were introduced to meet the changing needs of the population more
appropriately. In recent years, reorganization of the pharmaceutical market and the
bridging sectoral boundaries have gained importance. Currently, the revenue side of
statutory health and long-term care insurance are under discussion. The following table
(Table 21) shows the reforms that have shaped the German healthcare system since 2000.
92
Table 14: Pharmaceutical reforms in Germany, 2000-2006 Year Law Main cost reduction provision
2000 Statutory Health Insurance Reform Act of 1999
• Increasing focus on prevention, self-help, patient rights, and quality control
2002 Medication Expenditure Restriction Act • Aut Idem pharmacy substitution introduced
2003 Premiums • Increase of mandatory pharmacy rebates to 6% (from 5%)
• New mandatory rebates for pharmaceutical industry (6%) and wholesalers (3%)
2004 Contributions Security Act and the SHI Modernization Act
• Price-variant pharmacy rebates (6-10%) • New co-payments on physician visits (€10 per
quarter, except for prevention and referrals) • OTC products (i.e. non-prescription) excluded
from coverage (with exception of certain indications and children under 13 years of age)
• Higher co-payments on medication (10%, minimum €5, maximum €10)
• Mail-order pharmacies and individual ownership of up to four (regional) pharmacies allowed
• Reduction of pharmacy rebates to €2; 5% on prescribed OTC and not pre-packaged products
• Exclusion of non-sickness-related expenditures (e.g. contraception) from coverage
2006 AVWG (Law for the Economic Supply with Drugs)
• Mandates price freezes for two years • Further decreases in reference prices • 10% mandatory rebates for generics • A redefinition of how innovative drugs are
categorized • Financial reward/punishment system for
prescribers
Source: Adapted from Farrag & Riemer-Hommel, 2006; Walenta, Visiongain,
May 2006 D A T A M O N I T O R
93
10.8. Bibliography
o World Health Organization (2007), World health statistics [Internet], Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=deu&indicators=selected&language=en> [Accessed October 2007].
o World Health Organization (2007) World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=deu&indicators=healthpersonnel> [Accessed October 2007].
o VOI Consulting (2006), PharmaHandbook: A Guide to the International
Pharmaceutical Industry 2006.
o Datamonitor (2004), Exploiting technology opportunities in European healthcare,
2004, DMTC1017.
o World Health Organization (2004), Health systems in transition 2004 [Internet].
WHO Regional Office for Europe on behalf of the European Observatory on
Health Systems and Policies. Available from:
<http://www.euro.who.int/Document/E85472.pdf> [Accessed October 2007].
o OECD data (2007), OECD Germany Health data 2007 [Internet] Available from:
< http://www.oecd.org/dataoecd/45/55/38979836.pdf> [Accessed October 2007].
o Pharmaexecutive Europe, [Internet]. Available
from:<http://www.pharmexeceurope.com/europharmexec/article/articleDetail.jsp?
id=405242&pageID=1&sk=&date=> [Accessed October 2007].
o PIQUE report (2006), Liberalisation, privatization and regulation in the German
healthcare sector/hospitals, 2006, Wirtschafts- und Sozialwissenschaftliches
Institut. [Internet]. Available from:<
http://www.boeckler.de/pdf/wsi_pj_piq_sekkrankh.pdf> [Accessed October
2007].
94
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN GERMANY 2006 Table No 1. Total Physicians by Specialty and Gender SPECIALTY TOTAL MALE % FEMALE %
TOTAL PHYSICIANS 311,230 186,876 60 124,354 40 Anatomy 118 94 80 24 20 Anesthesiology 17,418 10,510 60 6,908 40 Biochemistry 61 47 77 14 23 Child and Youth Medicine 11,640 5,738 49 5,902 51 Child and Youth Psychiatry - Psychotherapy 1,354 612 45 742 55 Dermatology & Venereology 5,071 2,644 52 2,427 48 Human Genetics 227 94 41 133 59 Hygiene and Environmental Medicine 212 114 54 98 46 Internal Medicine and General Medicine 82,593 54,826 66 27,767 34 Laboratory Medicine 942 664 70 278 30 Legal Medicine 211 162 77 49 23 Maxillofacial Surgery 1,357 1,235 91 122 9 Microbiology, Virology & Infection Epidemiology 645 402 62 243 38 Neurology1 7,793 5,125 132 2,668 68 Neurosurgery 1,379 1,197 87 182 13 Nuclear Medicine 955 691 72 264 28 Occupational Medicine 2,703 1,555 58 1,148 42 Ophthalmology 6,544 3,804 58 2,740 42 Otolaryngology 5,527 3,838 69 1,689 31 Pathology 1,400 1,019 73 381 27 Pharmacology 481 382 79 99 21 Physical and Rehabilitative Medicine 1,680 1,066 63 614 37 Physiology 108 87 81 21 19 Psychiatry and Psychotherapy 7,148 3,884 54 3,264 46 Psychosomatic Medicine and Psychotherapy 3,861 1,968 51 1,893 49 Public Health Service 961 560 58 401 42 Radiology 6,456 4,543 70 1,913 30 Radiotherapy 844 482 57 362 43
95
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN GERMANY 2006 Table No 1. Total Physicians by Specialty and Gender (Cont…) SPECIALTY TOTAL MALE % FEMALE %
Surgery 28,414 24,367 86 4,047 14 Transfusional Medicine 512 279 54 233 46 Urology 4,883 4,379 90 504 10 Women’s Health 15,811 7,708 49 8,103 51 Without any Specialty 91,724 42,706 47 49,018 53 Other Specialties 197 94 48 103 52
1 Neurology+Nerve Medicine
Source: Bundesärztekammer (2007) Results of the physician statistics to 31 December 2006 [internet], Bundesärztekammer. Available from: <http://www.bundesaerztekammer.de/downloads/Aerztestatistik2006.pdf> [Accessed September 2007].
96
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN GERMANY 2006 Table No 2. Total Physicians by Specialty and Age SPECIALTY TOTAL UNDER 35 35-39 40-49 50-59 60-65 65 AND OVER
TOTAL PHYSICIANS 311,230 49,449 42,061 104,962 79,308 27,745 7,705 Anatomy 118 0 7 52 30 18 11 Anesthesiology 17,418 511 2,557 7,978 5,056 1,199 117 Biochemistry 61 0 1 17 29 12 2 Child and Youth Medicine 11,640 362 1,478 4,464 3,497 1,496 343 Child and Youth Psychiatry - Psychotherapy 1,354 25 170 612 393 123 31 Dermatology & Venereology 5,071 277 727 2,050 1,354 512 151 Human Genetics 227 7 35 90 66 20 9 Hygiene and Environmental Medicine 212 5 15 87 71 26 8
Internal Medicine and General Medicine 82,593 1,441 9,418 30,552 27,467 10,516 3,199 Laboratory Medicine 942 6 98 388 272 135 43 Legal Medicine 211 4 26 84 56 31 10 Maxillofacial Surgery 1,357 20 212 606 370 122 27 Microbiology, Virology & Infection Epidemiology 645 15 68 289 172 74 27
Neurology1 7,793 175 1,026 2,694 2,455 1,065 378 Neurosurgery 1,379 43 269 632 312 96 27 Nuclear medicine 955 31 130 430 215 107 42 Occupational Medicine 2,703 25 207 1,011 1,027 344 89 Ophthalmology 6,544 240 842 2,428 1,904 835 295 Otolaryngology 5,527 210 808 2,129 1,542 646 192 Pathology 1,400 16 133 598 407 192 54 Pharmacology 481 6 47 186 138 88 16 Physical and Rehabilitative Medicine 1,680 9 74 638 698 220 41 Physiology 108 0 5 38 34 24 7 Psychiatry and Psychotherapy 7,148 83 877 3,895 1,869 348 76 Psychosomatic Medicine and Psychotherapy 3,861 4 92 904 1,853 718 290 Public health service 961 1 13 261 526 143 17 Radiology 6,456 133 759 2,860 1,919 659 126 Radiotherapy 844 17 163 456 172 29 7
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PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN GERMANY 2006 Table No 2. Total Physicians by Specialty and Age (Cont…) SPECIALTY TOTAL UNDER 35 35-39 40-49 50-59 60-65 65 AND OVER
Surgery 28,414 604 4,331 11,750 8,383 2,722 624
Transfusional Medicine 512 8 52 266 143 38 5 Urology 4,883 130 749 2,004 1,336 550 114 Women’s Health 15,811 496 1,884 6,005 4,806 2,089 531 Without any Specialty 91,724 44,545 14,786 18,458 10,649 2,502 784 Other Specialties 197 0 2 50 87 46 12 1 Neurology+Nerve Medicine
Source: Bundesärztekammer (2007) Results of the physician statistics to 31 December 2006 [internet], Bundesärztekammer. Available from: <http://www.bundesaerztekammer.de/downloads/Aerztestatistik2006.pdf> [Accessed September 2007].
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PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN GERMANY 2006 Table No 3. Total Physicians by Specialty and Major Professional Activity
MAJOR PROFESSIONAL ACTIVITY
PATIENT CARE OTHER ACTIVITIES
SPECIALTY TOTAL TOTAL PATIENT
CARE
OFFICE BASED
HOSPITAL BASED
PUBLIC OFFICER/
CORPORATE BODY
OTHER NO MEDICAL
ACTIVITY
TOTAL PHYSICIANS 406,974 284,427 136,105 148,322 2,003 26,803 95,744 Anatomy 177 101 13 88 28 59 Anesthesiology 21,001 18,660 5,191 13,469 91 775 3,583 Biochemistry 106 5,553 5,521 32 23 45 Child and Youth Medicine 16,871 10,641 6,431 4,210 999 5,231 Child and Youth Psychiatry - Psychotherapy 1,659 1,277 649 628 77 305 Dermatology & Venereology 6,785 4,767 3,848 919 32 304 1,714
Human Genetics 258 195 81 114 32 31 Hygiene and Environmental Medicine 438 86 12 74 6 126 226 Internal Medicine and General Medicine 107,037 76,809 57,079 19,730 565 5,784 24,444 Laboratory Medicine 1,351 829 516 313 11 113 409 Maxillofacial Surgery 1,656 1,325 961 364 10 32 299 Microbiology, Virology & Infection Epidemiology 941 494 173 321 11 151 296 Neurology1 10,396 7,218 3,541 3,677 19 575 2,603 Neurosurgery 1,561 1,340 362 978 9 39 182 Nuclear Medicine 1,229 905 559 346 4 50 274
Occupational Medicine 4,013 266 2 264 19 2,174 1,310 Ophthalmology 8,749 1,084 265 819 25 204 2,205 Otolaryngology 7,325 5,353 4,162 1,191 32 174 1,798 Pathology 1,967 1,292 597 695 6 108 567 Pharmacology 749 201 16 185 280 268 Physical and Rehabilitative Medicine 2,083 1,529 535 994 151 403 Physiology 171 69 5 64 12 39 63 Psychiatry and Psychotherapy 7,907 6,560 2,554 4,006 6 588 759
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PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN GERMANY 2006 Table No 3. Total Physicians by Specialty and Major Professional Activity (Cont…)
MAJOR PROFESSIONAL ACTIVITY
PATIENT CARE OTHER ACTIVITIES SPECIALTY TOTAL TOTAL
PATIENT CARE
OFFICE BASED
HOSPITAL BASED
PUBLIC OFFICER/
CORPORATE BODY
OTHER NO MEDICAL
ACTIVITY
Psychosomatic Medicine and Psychotherapy 4,264 3,790 2,996 794 71 403
Public Health Service 1,561 50 21 29 9 911 600 Radiology 8,634 6,141 2,817 3,324 3 315 2,178 Radiotherapy 963 821 210 611 23 119 Right Medicine 310 131 10 121 1 80 99 Surgery 35,681 16,697 6 16,691 100 1,542 7,267 Transfusional Medicine 655 386 51 335 4 126 143 Urology 6,156 4,735 2,821 1,914 15 148 1,273
Women’s Health 20,933 15,234 10,586 4,648 2 577 5,122 Without any Specialty 122,799 66,332 2 66,330 987 10,073 31,075 Other Specialties 588 86 42 44 2 111 391 1 Neurology+Nerve Medicine
Source: Bundesärztekammer (2007) Results of the physician statistics to 31 December 2006 [internet], Bundesärztekammer. Available from: <http://www.bundesaerztekammer.de/downloads/Aerztestatistik2006.pdf> [Accessed September 2007].
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11. Italy
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11.1. Introduction to Italy
Italy is located on the Italian Peninsula in Southern Europe, and on the two largest islands
in the Mediterranean Sea, Sicily and Sardinia. Italy shares its northern Alpine boundary
with France, Switzerland, Austria and Slovenia. The independent states of San Marino
and the Vatican City are enclaves within the Italian Peninsula, while Campione d'Italia is
an Italian exclave in Switzerland.
Today, Italy is a democratic republic, and a developed country with the 7th-highest GDP
(nominal) and the 20th-highest Human Development Index rating in the world. It is a
founding member of what is now the European Union (having signed the Treaty of Rome
in 1957), and also a member of the G8, the Council of Europe, the Western European
Union, and the Central European Initiative. Beginning January 1, 2007, Italy became a
non-permanent member of the United Nations Security Council. Italy is subdivided into
20 regions (regioni, singular regione). Five of these regions enjoy a special autonomous
status that enables them to enact legislation on some of their specific local matters, such
as Sardinia and Sicily. Italy is further divided into 109 provinces (province) and 8,101
municipalities (comuni) (Figure 9).
The latest population estimate from ISTAT (Italian Statistics Office) shows 59,206,382
inhabitants in Italy in February 2007 - (source:
http://demo.istat.it/bilmens2007gen/index.html), an increase of 49,084 people from a
month earlier. Italy has the fourth largest population in the European Union (after
Germany, France and the United Kingdom), and the 22nd in the world. Gradual increase
of population is mainly supplemented by immigrants and an increase in life expectancy of
79.81 years. Despite population growth, Italy is rapidly aging. Though the Italian fertility
rate is climbing gradually, it sits at 1.35 children per woman, almost one in five Italian
inhabitants is a pensioner; if this aging trend continues, the Italian population could
shrink by a quarter by 2050.
Italy has the fifth highest population density in Europe with 196 persons per square
kilometer. The highest density is in Northwestern Italy, as two regions out of twenty
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(Lombardy and Piedmont) combined, contain one quarter of the Italian population, where
an estimated 7.4 million people live in the metropolitan Milan area. The literacy rate in
Italy is 98% overall, and school is mandatory for children aged 6 to 18. Approximately
two thirds of the population live in urban areas, which is much lower than other Western
European nations.
Figure 9: Map of Italy showing key cities and regions
Source: www.wikipedia.org D A T A M O N I T O R
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11.2. Italian healthcare system
The National Health Service (NHS) financed by general taxation, aims at granting
universal access to a uniform level of care throughout the country. Universal coverage
has been achieved, although regions widely differ in terms of health care and health
expenditure, with a distinct north-south divide.
Italy has a highly decentralized healthcare system, based on national, regional and local
levels of healthcare provision. The state has exclusive power to define the basic benefit
package (LEA; livelli essenziali di assistenza), which must be uniformly provided
throughout the country, and the 20 regions have responsibility for organizing and
administering the health care system. Local health units (public health enterprises legally
independent from the region) have responsibility for delivering health care services at the
local level, serving geographical areas with average populations of about 300,000. The
following figure gives an overview of the healthcare system in Italy (Figure 10).
Figure 10: Organizational structure of the Italian healthcare system
Source: internal secondary research D A T A M O N I T O R
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11.3. Healthcare insurance
Italian healthcare is primarily provided by a public system, although the Italian National
Health Service (SSN; Servizio Sanitario Nationale) finances a relatively low level of
overall healthcare expenditure. Approximately one third of the Italian population has
private healthcare cover, which, because of the relatively poor standard of public
healthcare, tends to replace and duplicate SSN services. The use of private healthcare in
Italy therefore differs from countries such as France, where private healthcare is used to
supplement public healthcare and cover patient co-payments. For this reason, private
insurance primarily covers ambulatory specialist care and private hospital care for minor
surgery.
11.4. Service delivery
Primary care is delivered by self-employed GPs and physicians, who are independent
contractors of the NHS. They act as gatekeepers to secondary care. Physicians work
under government contract and are paid through capitation fees. Secondary care is
provided by local health units, public hospital trusts and private accredited hospitals.
Local health units are in charge of protecting and promoting public health mainly through
disease prevention (especially immunization), health promotion and food control.
Specialized services are provided either directly by local health units or through
contracted-out public (61%) and private (mainly not-for-profit) facilities accredited by
local health units.
11.5. Healthcare financing and expenditure
Total health spending accounted for 8.4% of GDP in 2004. Italy ranks below the OECD
average in terms of health spending per capita, with spending of about 2392 USD in 2004
(adjusted for purchasing power parity). Between 1999 and 2004, health spending per
capita in Italy increased in real terms by 3.5% per year on average.
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According to OECD health data (2006), the share of public spending in Italy was 76.4%
in 2004. Private healthcare is available to those who can afford private insurance or direct
payment. About 15% of the population has complementary private health insurance either
individually subscribed or offered by employers (internal secondary research). Use of
private services is encouraged through the tax system; patient expenditures on private
healthcare are eligible for tax deductions and credits.
The rise in pharmaceutical spending has been one of the factors behind the rise in total
health spending in Italy. In 2004, spending on pharmaceuticals accounted for 21.4% of
total health spending in Italy. For 2003, expenditure can be split into: the hospital sector
(48%), drug spending (15%), outpatient specialist care (12%) and other (25%) (France et
al., 2005). The following table (Table 15) shows the key health expenditure indicators in
2004.
Table 15: Italian healthcare spending statistics
Indicator Value Total expenditure on health as percentage of gross domestic product 8.4% (2004) Public expenditure on health as percentage of total expenditure on health 76.4% (2004) Private expenditure on health as percentage of total expenditure on health 23.6% (2004) Out-of-pocket expenditure as percentage of private expenditure on health 84.4% (2004) Private prepaid plans as percentage of private expenditure on health 3.6% (2004) Per capita total expenditure on health (adjusted for purchasing power parity) $2,392 (2004)
Source: WHO sources World Health Statistics 2007 D A T A M O N I T O R
The Italian healthcare system is based on a National Health Service (NHS) model.
Citizens and their employers make compulsory social contributions to the central
government, which in turn finances the National Health Fund (NHF). Money from this
fund is allocated to the regional authorities, who are responsible for funding the local
health units. The local health units directly fund the providers, paying out capitations for
GPs, salaries for public hospitals and per diems for hospitals under contract with the
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NHF. This complicated method of funding has resulted in deep regional inequalities in
healthcare expenditures.
11.6. Resources
According to the OECD data (2006), Italy had 4.2 practicing physicians per 1,000
population in 2004 and 5.4 qualified nurses per 1,000 population in 2003. The number of
acute care hospital beds was 3.7 per 1,000 population in 2003. As in most OECD
countries, the number of hospital beds per capita in Italy has fallen over time. This
decline has coincided with a reduction of average length of stays in hospitals and an
increase in the number of surgical procedures performed on a same-day (or ambulatory)
basis. The following table (Table 16) gives the absolute number and density of physicians
and nurses in the recent years. For a complete review of the most up to date physician
statistics, please refer to the Italian physician statistics section of this report.
Table 16: Italian physician and nurse numbers Resource Indicator Value (year) Physicians (number) 241,000 (2004) Physicians (density per 1,000 population) 4.2 (2004) Nurses (number) 312,377 (2003) Nurses (density per 1,000 population) 5.4 (2003)
Source: OECD Healthcare Statistics, 2007 D A T A M O N I T O R
11.7. Italian pharmaceutical market
Italy is the fourth largest market in Europe and the sixth largest in the world. It is the third
largest producer of pharmaceuticals in Europe and the fifth largest in the world. There
were 240 pharmaceutical companies in Italy with 74,000 employees in 2004. Menarini,
the largest Italian pharmaceutical company had 2004 sales of USD 2.8 billion. Other
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major companies include Sigma-Tau, Recordati, Chiesi and Zambon. The following table
(Table 17) shows retail sales by therapeutic category during 2005.
Table 17: Italian retail sales by therapeutic category, 2005 Category $m % change Cardiovascular 3,718 -2% Central Nervous System 1,939 1% Alimentary/ Met. 2,131 2% Respiratory 1,277 6% Anti-infectives 1,237 -1% Musculoskeletal 834 -9% Genitourinary 896 2% Cytostatics 535 -7% Blood Agents 552 -3% Dermatologicals 451 2% Sensory Organs 329 1% Diagnostic Agents 318 12% Systemic Hormones 198 -2% Miscellaneous 38 -8% Hospital Solutions 41 -14% Parasitology 8 9% Total 14.502 4%
Source: internal secondary research D A T A M O N I T O R
The SSN has attempted a variety of measures to control rising costs and has focused on
its prescription drug funding as one of the most readily managed segments of its budget.
The abolition of co-payments of prescription drugs resulted in a 25% decline in the
amount of total drug payments from private sources. The following table (Table 18) lists
the measures taken to reduce pharmaceutical spending since 2000.
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Table 18: Pharmaceutical reforms in Italy, 2001-2006
Year Measure 2000 • Nation wide elimination of patient co-payments 2001 • Prescribing restrictions lifted for statins.Cox-2 inhibitors. other popular
therapeutic categories 2002 • Reinstatement of co-payments at regional discretion.
• 5% across-the-board price cuts 2003 • Italy becomes the first major European market to implement reference
pricing at the pharmacological category rather than active ingredient level • 7% across-the-board price cuts • Elimination of Class B (Partially reimbursed) categories
• 5% tax on promotional spending 2004 • Passage of Decree 156, which mandates that drug spending not exceed 13%
of the total health bill (or 16% when hospital drugs are included). • Pharmaceutical manufacturers pay 60% of overspending, with the regions
paying the remainder
• Overspending of the target results in 6.8% across-the-board price cuts introduced in June 2004 and ran through October 2005
2005 • Selective reductions of up to 10% on drugs that grew faster than the market in 2004 (56 active ingredients included).
• New drugs must negotiate price-volume agreements as condition of admission to reimbursement lists.
• Revisions to reimbursement lists.
• Measures result in total savings of € 870 million during the year 2006 • Products with selective reductions restored to December 2004 prices
• 2005 Expenditures totaled 17.8% of health budget versus 16% target; leading to a 4.4% across-the-board price cut for reimbursed products.
• Mandatory discount of 1% (ex-factory) for reimbursed products sold in the retail channel.
• 20% reductions (at pharmacy) of Class C (non0reimbursed) drugs.
Source: Datamonitor research D A T A M O N I T O R
According to secondary research, generics grew to 10.1% of market value and 21.7% of
prescription volume by early 2005 – however, about 81% was captured by branded
generics. Sales of true generics totaled only $522 million in 2005. This represented 2.4%
of the retail value and approximately 5% of retail volume. Sales in the true generic sector
were up by 49% in 2005. Despite growth of the generic sector, Italy is likely to remain a
brand-oriented market for some years.
Pharmacists are now legally obligated to switch branded prescriptions to generics, if the
option exists and if the physician has not marked “do not substitute”. Physicians are also
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required to inform patients of the existence of generics and low cost prescribing is
reinforced using computerized tracking systems.
According to secondary research, sales of Class A (reimbursable) generics in 2005 were
dominated by gabapentin (Neurontin), which generated 46% of total reimbursable generic
sales. Class C (non-reimbursable) is dominated by lorazepam (Xanax), which had 32% of
sales. There were 2,273 total generic drugs with 139 different active ingredients in 2006.
This translates to 16.3 versions for each active ingredient. The median and average retail
prices were $9.4 and $13.6, respectively.
Pharmaceutical research spending totaled $1,252m in 2004, up from $1214m in 2003 and
$1,090 million in 2002 (secondary research). This represents 7% of total sales. Italian
companies have traditionally focused on generic rather than original drug development. A
new committee (CRS) within the AIFA (Italian Medicines Agency) was established in
the first quarter of 2005 to promote the domestic pharmaceutical research sector. A
National Monitoring Centre for Clinical Trials (Osservatorio Nazionale per le
sperimentazione cliniche) was established as a division of the AIFA to modernize and
support the clinical research industry in Italy. Guaranteeing a basic benefit package free
of user charges as well as uniform levels and quality of healthcare across the regions are
the current challenges of the Italian healthcare system.
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11.8. Bibliography
o World Health Organization (2007), World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=ita&indicators=selected&language=en> [Accessed October 2007].
o World Health Organization (2007) World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=ita&indicators=healthpersonnel> [Accessed October 2007].
o World Health Organisation (2001), Health systems in transition 2001 [Internet].
WHO Regional Office for Europe on behalf of the European Observatory on
Health Systems and Policies. Available from:
<http://www.euro.who.int/document/e73096.pdf > [Accessed October 2007].
o VOI Consulting (2006), PharmaHandbook: A Guide to the International
Pharmaceutical Industry 2006.
o OECD data (2007), OECD Italy Health data 2007 [Internet] Available from: <
http://www.oecd.org/dataoecd/45/52/38979929.pdf> [Accessed October 2007].
o World Health Organisation Regional Office for Europe, Highlights on health
(2004), [Internet]. Available from:
<http://www.euro.who.int/document/E88550.pdf> [Accessed October 2007].
o Datamonitor (2006), Pricing & Reimbursement in Europe: Can the drive for cost
effectiveness overcome cost containment?, September 2006, DMHC2238.
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PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ITALY 2006 Table No 1. Total Physicians by Specialty and Gender SPECIALTY TOTAL MALE % FEMALE %
Total 293,933 216,547 74 77,386 26 Allergy / Immunology 1,673 1,034 62 639 38
Anatomic / Clinical Pathology 1,250 804 64 446 36 Anesthesiology 10,070 7,182 71 2,888 29 Cardiology 13,974 11,681 84 2,293 16 Cardiovascular Surgery 549 523 95 26 5 Clinical Biochemistry 367 200 54 167 46 Clinical Pathology 2,419 1,558 64 861 36 Community Medicine 15 15 100 0 0 Dermatology and Venereology 4,664 3,058 66 1,606 34 Endocrinology 6,174 3,982 64 2,192 36
Gastroenterology 6,242 4,941 79 1,301 21 Gastrointestinal Surgery 2,091 1,835 88 256 12 General Physicians 57,554 40,288 70 17,266 30 General Surgery 13,314 12,071 91 1,243 9 Geriatric Medicine 4,266 2,989 70 1,277 30 Gynecology and Obstetrics 12,804 8,224 64 4,580 36 Hematology 4,152 2,737 66 1,415 34 Hygiene / Preventive Medicine 11,411 8,101 71 3,310 29
Infantile Neuropsychiatry 2,372 983 41 1,389 59 Infectious Disease 2,710 1,923 71 787 29 Internal Medicine 8,910 6,902 77 2,008 23 Legal Medicine 626 514 82 112 18 Maxillofacial Surgery 679 634 93 45 7 Medical Genetics 193 99 51 94 49 Medical Toxicology 856 648 76 208 24 Microbiology and Virology 653 413 63 240 37
Nephrology 2,869 1,975 69 894 31 Neurology 6,518 4,364 67 2,154 33
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PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ITALY 2006 Table No 1. Total Physicians by Specialty and Gender (Cont…) SPECIALTY TOTAL MALE % FEMALE %
Neurosurgery 766 709 93 57 7
Nuclear Medicine 1,021 778 76 243 24 Nutrition 1,679 1,012 60 667 40 Occupational Medicine 6,449 5,083 79 1,366 21 Odontostomatology 20,793 17,232 83 3,561 17 Oncology 3,764 2,673 71 1,091 29 Ophthalmology 6,038 4,376 72 1,662 28 Orthopedic Surgery and Traumatology 7,230 6,862 95 368 5 Otolaryngology 5,938 4,986 84 952 16
Pediatric Surgery 724 586 81 138 19 Pediatrics 18,902 9,853 52 9,049 48 Pharmacology 616 447 73 169 27 Physical Medicine and Rehabilitation 4,783 3,478 73 1,305 27 Psychiatry 7,418 4,754 64 2,664 36 Pulmonology 6,548 5,277 81 1,271 19 Radiation Oncology 280 192 69 88 31 Radiodiagnostics 7,197 5,912 82 1,285 18 Reconstructive Plastic Surgery 1,214 1,046 86 168 14 Rheumatology 1,837 1,243 68 594 32 Sports Medicine 4,156 3,631 87 525 13 Thoracic Surgery 1,176 1,108 94 68 6 Tropical Medicine 347 284 82 63 18 Urology 3,829 3,670 96 159 4 Vascular Surgery 1,853 1,677 91 176 9
Source: International Department, Italian Medical Council (FNOMCEO), 2006, [Accessed October 2007].
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12. Japan
114
12.1. Introduction to Japan
Japan is an island country in East Asia. Located in the Pacific Ocean, it lies to the east of
China, Korea and Russia, stretching from the Sea of Okhotsk in the north to the East
China Sea in the south. The characters that make up Japan's name mean "sun-origin",
which is why Japan is sometimes identified as the "Land of the Rising Sun". A major
economic power, Japan has the world's second largest economy by nominal GDP. It is a
member of the United Nations, G8, G4 and APEC, with the world's fifth largest defense
budget. It is also the world's fourth largest exporter and sixth largest importer and a world
leader in technology and machinery.
While there exists eight commonly defined regions of Japan, administratively Japan
consists of forty-seven prefectures, each overseen by an elected governor, legislature and
administrative bureaucracy. The city of Tokyo, which with just over 8 million
inhabitants, has the highest number of inhabitants of all cities in Japan, is further divided
into twenty-three special wards, each with the same powers as cities. The nation is
currently undergoing administrative reorganization by merging many of the cities, towns
and villages with each other. This process will reduce the number of sub-prefecture
administrative regions and is expected to cut administrative costs. A map of Japan, along
with the names of the 47 prefectures, is shown in the following figure (Figure 11).
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Figure 11: Geographical map of Japan with location and names of prefectures
Source: www.servas-japan.org D A T A M O N I T O R
Japan's population is estimated at around 127.4 million. For the most part, Japanese
society is linguistically and culturally homogeneous with small populations of foreign
workers, Zainichi Koreans, Japanese Chinese, Japanese Filipinos, Japanese Brazilians
and others. The most dominant native ethnic group is the Yamato people; the primary
minority groups include the indigenous Ainu and Ryukyuans, as well as social minority
groups like the burakumin. Japan has one of the highest life expectancy rates in the
world, at 81.25 years of age as of 2006. However, the Japanese population is rapidly
aging, the effect of a post-war baby boom followed by a decrease in births in the latter
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part of the twentieth century. In 2004, about 19.5% of the population was over the age of
65.
12.2. Japan’s healthcare system
Healthcare provision (including inpatient, outpatient and tertiary care) in Japan is covered
by public universal insurance funded by contributions from employees, employers and
the government. The system has been in place since 1961, when every patient was made
to join employee insurance programs or the National Health Insurance (NHI) system.
Approximately 80% of Japan’s healthcare spending is funded by public sources, which is
considerably higher than the US, where 45% of healthcare is funded by public sources.
However, it is similar to other major markets in Europe, which have healthcare systems
dominated by government-led public healthcare provision.
12.3. Public healthcare insurance in Japan
People are assigned an insurance scheme based on their employment or residence. These
insurance schemes, which are not-for-profit, are regulated and in some cases managed by
the government, and provision is thought of as egalitarian, with patients historically
shouldering a minimal burden of healthcare costs. Company employees are covered by
the Social Insurance System (SIS), representing approximately 63% of the population.
These are delivered through approximately 1,800 entities nationwide, which are known as
Health Insurance Societies. Premiums are based on the employees’ incomes and represent
approximately 8.5% of their salaries. The remaining 37% of the population are covered
by NHI, which is provided through approximately 3,400 regional plans. The wide range
of insurance schemes vary in terms of contribution, national subsidies and benefits levels,
although the reimbursement system is the same. Public insurance bodies cannot compete
for members because patients are not allowed to choose their fund, nor can they tailor
their product offering, choose which patients to cover, or negotiate with providers.
Therefore, they have limited scope for containing costs.
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Additionally, patients are also covered by long-term care insurance (Kaigo Hoken),
which was initiated in April 2000 to cover the elderly population. This insurance is
designed to increase the percentage of elderly patients who can live on their own by
providing them with home-care services. The premiums for this insurance are shared
equally between the government and the population aged over 40. To qualify for this type
of insurance, patients must be older than 65, or 40–64 and suffering from one of 15
conditions (e.g. pre-senile dementia). This has been a key strategy designed to tackle the
ageing population and its creation highlights the fact that the government realizes it has to
take significant steps to cope with this problem. This sector of the market is set to
experience significant growth given the ageing population, with Japan’s largest life
insurance company Nippon Life estimating that the market will be worth ¥9 trillion in the
short term (Economist Intelligence Unit, 2005).
12.4. Hospitals remain the first port-of-call
Japan has a much stronger in-patient culture than European countries, with 43% of the
total pharmaceutical spending generated by the hospital sector. In contrast, 27% of drug
spending was generated by the primary care setting (Scrip #3112, December 2005). This
can be compared to European markets such as France, where drugs prescribed in
hospitals represent only 17% of total pharmaceutical spending, compared to retail
pharmacies in the outpatient setting, which account for 77% (Chicoye, 2003). Despite
this, healthcare provision is increasingly weighted towards outpatient care, since Japan
has the highest rate of physician visits and the lowest rate of hospital admissions. This
apparent contradiction can be explained by three factors:
o most patients choose hospitals as their first port-of-call when they have a medical
problem. This is partly because hospitals have evolved to offer primary care in an
outpatient setting as part of the blurring between primary and secondary care in
Japan. It also relates to the fact that patients believe specialists at large hospitals
provide the best medical advice;
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o when patients get into hospital, they stay longer: Japan has the longest average
length of stay (ALOS) per patient in the major markets (Scrip #3134, February
2006);
o most institutional care for the elderly is provided by hospitals (often as part of
shakaiteki nyuin: the process of social admissions), rather than tertiary care
common in Europe. These long-term inpatients remain in hospital because of a
lack of in-home care services, a fear of disease and the lower co-payment burden.
If these long-term inpatients were taken out of total healthcare expenditure, the
total healthcare spending for the elderly would be cut by 25% (Fukawa &
Izumida, 2004).
Additionally, patients are also covered by long-term care insurance (Kaigo Hoken),
which was initiated in April 2000 to cover the elderly population. The premiums for this
insurance are shared equally between the government and the population aged over 40.
This sector of the market is set to experience significant growth given the ageing
population, with Japan’s largest life insurance company Nippon Life estimating that the
market will be worth ¥9 trillion in the short term (Datamonitor DMHC2265). There is a
wide range of bodies and groups representing a number of different healthcare providers
and users that affect healthcare provision in Japan, as detailed in the following figure
(Figure 12).
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Figure 12: Stakeholders impacting healthcare provision in Japan
Source: internal secondary research D A T A M O N I T O R
12.5. Service delivery
Patients are able to seek care at hospitals of their choice. By law, hospitals and clinics are
owned by physicians and may not be operated for profit. Despite pressure from trading
partners and the possibility of reducing costs, the legalization of the for-profit sector was
denied in 2001 and will probably not be authorized on a broad scale in the near future.
There are, however, 59, investor owned hospitals that existed prior to passage of the 1948
law. A July 2003 law allowed for profit hospitals in designated “deregulation zones,” but
these are completely excluded from the reimbursement system (internal secondary
research).
The lack of a referral system, where GPs act as a gatekeeper to secondary and tertiary
hospital care, has resulted in a blurring of functions. Primary care is delivered by hospital
outpatient departments as well as GP clinics and inpatient care is offered by clinics as
well as hospitals. The government is attempting to reform and rationalize the system to
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restrict inpatient care to hospitals and outpatient care to GP clinics and its efforts have
had some effect.
12.6. Healthcare financing and expenditure
Total health spending accounted for 8.0% of GDP in Japan in 2004. Japan’s health
spending per capita, amounted to 2358 USD in 2004 (adjusted for purchasing power
parity). Health spending per capita in Japan rose, in real terms, by 2.1% between 2000
and 2004. In Japan, 81.7% of health spending is funded by public sources, well above the
average of 72.5% in OECD countries. The following table (Table 19) shows the key
health expenditure indicators in 2004.
Table 19: Key Japanese health expenditure indicators, 2004 Indicator Value (year) Total expenditure on health as percentage of gross domestic product 8% (2004) Public expenditure on health as percentage of total expenditure on health 81.7% (2004) Private expenditure on health as percentage of total expenditure on health 18.3% (2004) General government expenditure on health as percentage of total government expenditure 17.2% (2004) Out-of-pocket expenditure as percentage of private expenditure on health 94.9% (2004) Per capita total expenditure on health (adjusted for purchasing power parity) $2,358 (2004)
Source: OECD Health data, 2007 D A T A M O N I T O R
Over the last several years, the government has made a number of moves to shift the
burden of payment to patients: in 2002, elderly patients were required to contribute 10%
co-payments, in April 2003, the co-payment for rest of the population was raised to 30%
from 20%, and the out-of-pocket ceiling for expensive operations was raised over a three
year period ending in 2003. These cost-sharing initiatives are continuing, with the most
prominent example being a new health insurance plan for people 75 years or older. This
plan will commence in 2008 and will require participants to bear a higher proportion of
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the cost for their care. As the first step, wealthier patients over 70 will have to meet the
30% co-payment level starting in October 2006 (internal secondary research).
12.7. Resources
According to OECD Health data (2007), Japan had 2 practicing physicians per 1,000
population in 2004. On the other hand, Japan had 9 nurses per 1,000 population in 2004.
Japan had the highest number of acute care hospital beds of all OECD countries, with 8.2
beds per 1,000 population in 2005. The Japanese healthcare system has several distinctive
features compared with the US and Europe. It has a high number of hospital beds per
person (about 16 per 1,000) and long hospital stays (around 30 days on average), while
the relatively low number of doctors per person and the lack of an appointment system
results in overcrowding and long waits for outpatients (Macro environmental healthcare
issues in Japan, 2004). The following table (Table 20) gives the absolute number and
density of physicians and nurses in the recent years.
Table 20: Physicians and Nurses
Resource indicator Value (year) Physicians (number) 251,889 (2002) Physicians (density per 1,000 population) 2.0 (2004) Nurses (number) 993,628 (2002) Nurses (density per 1,000 population) 9.0 (2004)
Source: OECD Health Data, 2007 D A T A M O N I T O R
According to the Pharma Handbook (2006), Japan has over 9,000 hospitals with over 1.6
million beds. About 8,000 hospitals are privately owned, approximately 1,000 are owned
by local government authorities and about 300 are owned by the national government or
by national government agencies. Over half of the beds are acute, while long-term care
and psychiatric care beds both number approximately 350,000. Of the approximately 1.9
million beds in the healthcare system, according to the October 2001 census, around 11%
were in GP clinics (internal secondary research). For a complete review of the most up to
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date physician statistics, please refer to the Japanese physician statistics section of this
report.
Table 21: The number of hospitals, GP clinics, dental clinics, plus beds, in Japan in 2001
Institution No. of institutions No. of beds Hospitals 9,239 1,646,797 GP clinics 94,019 209,544 Dental clinics 64,297 153
Source: Ministry of Health, Labor and Welfare D A T A M O N I T O R
12.8. Japanese pharmaceutical market
Japan accounts for 10% of global pharmaceutical sales, making it the world’s second
largest market. IMS reports that total market value reached $60.3 billion in 2005, an
increase of 7% over 2004 (internal secondary research). Per capita consumption in 2005
was $411. The following table (Table 22) shows the sales by therapeutic category in
2005.
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Table 22: Japanese pharmaceutical sales by therapeutic category, 2005
Category Sales $m
2005
Growth on Previous
year % Cardiovascular 12,049 6% Central Nervous System 4,942 8% Alimentary/ Metabolic 8,474 4% Respiratory 4,357 15% Antiinfectives 6,304 8% Musculoskeletal 3,856 5% Genitourinary 1,335 7% Cytostatics 5,288 13% Blood Agents 3,801 5% Dermatologists 1,295 -3% Sensory Organs 1,859 8% Diagnostic Agents 2,215 8% Systemic Hormones 1,129 2% Miscellaneous 1,568 5% Hospital Solutions 1,795 0% Parasitology 4 -10% Total 60,271 7%
Source: internal secondary research D A T A M O N I T O R
Generic products have a very low penetration in the Japanese market: 11% of market
volume and 6% of market value in 2005 (internal secondary research). Brands in Japan
tend to lose 5% to 10% of market share annually after generic entry.
Members of the Japanese Pharmaceutical Manufacturers Association spent an average of
13.7% of sales on research and development in the first half of 2005. This compares to
13% in the same period of 2004 and suggests a long-term growth in R&D spending. It is
estimated that the cost of enrollment in Japanese clinical trials amounts to $50,000 per
patient - much higher than most markets. Additionally, the clinical trials system has been
liberalized in recent years with greater recognition of foreign-generated data and easier
procedures for patient enrollment.
124
Until the late 1990s, the government required extensive domestic testing as a condition
for approval. High costs and the ability to use outside data have severely restricted
clinical trial activity: total trials fell to 361 in 2003 from 1,200 in 1993. As part of a
collaborative industry-government plan to promote the clinical trials industry, the
National Center for Highly Specialized Medical Treatment has been working to create a
large scale-network of numerous medical institutions that will conduct both physician-led
and company-sponsored trials. Until 2003, data generated in university-led trials could
not be used for drug approval purposes. Additionally, schools are now allowed to set up
separate entities (independent administrative institutions or IAI) for commercialization
purposes. As a result of the regulatory changes, academic researchers are becoming
increasingly involved in the drug development process. There are 32 contract research
firms in Japan.
The Japanese industry has seen considerable consolidation in recent years. In large part,
this is due to the scale required to compete on a global basis, but changes in corporate law
and the reduction of barriers to foreign companies in Japan have also contributed. A 2006
law allowing foreign companies to purchase Japanese firms via share swaps should
accelerate the acquisition process. In addition to M&A activity, globalization was also
evidenced by a 26% increase in partnership arrangements in 2005 over the previous year.
The Japanese biotech industry’s total market capitalization is approximately $5.1 billion
– making it the fourth largest in the world. Three companies (AnGes MG, Sosei, Takara
Bio) account for approximately 62% of this amount. Including these majors, there are 464
biotech companies employing some 4,200 people. Life science accounts for 12%, or $133
million, of Japanese venture capital investments.
125
12.9. Bibliography
o World Health Organization (2007), World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=jp&indicators=selected&language=en> [Accessed October 2007].
o OECD data (2007), OECD Japan Health data 2007 [Internet] Available from: <
http://www.oecd.org/dataoecd/45/51/38979974.pdf> [Accessed October 2007].
o Datamonitor (2006), Pricing and Reimbursement in Japan: Costly healthcare
system inefficiencies increase the focus on healthcare cost containment,
November 2006, DMHC2265.
o VOI Consulting (2006), PharmaHandbook: A Guide to the International
Pharmaceutical Industry 2006.
o Datamonitor (2004), Macro-environmental healthcare issues in Japan.
126
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN JAPAN 2004 Table No 1. Total Physicians by Specialty and Gender SPECIALTY TOTAL MALE % FEMALE %
TOTAL PHYSICIANS 256,668 214,628 84 42,040 16 Allergy 207 167 81 40 19 Anesthesiology 6,397 4,538 71 1,859 29 Cardiology 9,009 8,139 90 870 10 Cardiovascular Surgery 2,632 2,533 96 99 4 Cosmetic Surgery 342 300 88 42 12 Dermatology 7,780 4,824 62 2,956 38 Gastroenterology 10,352 9,270 90 1,082 10 General Medicine 3,883 2,608 67 1,275 33
Gynecology 1,562 1,170 75 392 25 Internal Medicine 73,670 62,749 85 10,921 15 Lung Surgery 1,110 1,059 95 51 5 Neurology1 3,908 3,194 166 714 34 Neurosurgery 6,287 6,052 96 235 4 Obstetrics 431 340 79 91 21 Obstetrics and Gynecology 10,163 7,951 78 2,212 22 Ophthalmology 12,452 7,867 63 4,585 37 Orthopedics 18,771 18,087 96 684 4 Otolaryngology 9,076 7,408 82 1,668 18 Pediatric Surgery 682 577 85 105 15 Pediatrics 14,677 10,105 69 4,572 31 Plastic Surgery 1,765 1,402 79 363 21 Proctology 393 379 96 14 4 Psychiatry 12,151 9,906 82 2,245 18 Psychosomatic Medicine 752 591 79 161 21 Pulmonology 3,655 3,056 84 599 16
Radiology 4,780 3,899 82 881 18 Rehabilitation 1,696 1,402 83 294 17
127
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN JAPAN 2004 Table No 1. Total Physicians by Specialty and Gender (Cont…) SPECIALTY TOTAL MALE % FEMALE %
Rheumatology 640 516 81 124 19
Surgery 23,240 22,160 95 1,080 5 Tracheoesophagology 40 38 95 2 5 Unknown 264 197 75 67 25 Urology 6,032 5,838 97 194 3 Venereology 22 21 95 1 5 Others2 7,847 6,285 165 1,562 35 1 Neurology+Nerve Internal Medicine 2 Others+Major Diagnosis and Treatment
Source: Statistics and Information Department, Minister's Secretariat, Ministry of Health, Labour and Welfare, Japan, [Accessed October 2007].
128
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN JAPAN 2004 Table No 2. Total Physicians by Specialty and Age SPECIALTY TOTAL UNDER 35 35-44 45-54 55-64 65 AND OVER
TOTAL PHYSICIANS 256,668 256,668 513,336 770,004 1,283,340 3,080,016 Allergy 207 35 44 62 34 32 Anesthesiology 6,397 2274 2134 1419 459 111 Cardiology 9,009 2651 3197 2019 795 347 Cardiovascular Surgery 2,632 781 967 631 211 42 Cosmetic Surgery 342 94 134 77 26 11 Dermatology 7,780 1708 2022 1902 1040 1108 Gastroenterology 10,352 2503 3195 2463 1287 904 General Medicine 3,883 3678 119 31 16 39
Gynecology 1,562 118 259 330 236 619 Internal Medicine 73,670 11224 15330 18252 11479 17385 Lung Surgery 1,110 310 429 276 84 11 Neurology1 3,908 1,123 1,285 942 365 193 Neurosurgery 6,287 1414 2056 1701 800 316 Obstetrics 431 100 112 109 74 36 Obstetrics and Gynecology 10,163 1976 2314 2170 1592 2111 Ophthalmology 12,452 2771 3724 2861 1232 1864 Orthopedics 18,771 3870 5606 4511 2469 2315 Otolaryngology 9,076 1712 2358 2101 1034 1871 Pediatric Surgery 682 208 203 150 97 24 Pediatrics 14,677 3330 3239 3819 2171 2118 Plastic Surgery 1,765 695 587 337 102 44 Proctology 393 16 92 123 92 70 Psychiatry 12,151 2455 3395 2911 1586 1804 Psychosomatic Medicine 752 105 218 253 94 82 Pulmonology 3,655 1194 1229 826 254 152
Radiology 4,780 1396 1758 1138 341 147 Rehabilitation 1,696 285 514 425 210 262
129
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN JAPAN 2004 Table No 2. Total Physicians by Specialty and Age (Cont…) SPECIALTY TOTAL UNDER 35 35-44 45-54 55-64 65 AND OVER
Rheumatology 640 179 210 138 73 40
Surgery 23,240 5057 6309 5027 3190 3657 Tracheoesophagology 40 5 20 10 2 3 Unknown 264 105 45 20 26 68 Urology 6,032 1410 1888 1555 775 404 Venereology 22 1 3 4 3 11 Others2 7,847 2,861 1,711 1,413 842 1,020 1 Neurology+Nerve Internal Medicine 2 Others+Major Diagnosis and Treatment
Source: Statistics and Information Department, Minister's Secretariat, Ministry of Health, Labour and Welfare, Japan, [Accessed October 2007]..
130
13. Spain
131
13.1. Introduction to Spain
Spain is a Western European country. The country consists of Peninsular Spain which is
located between the Mediterranean Sea and the Atlantic Ocean, two archipelagos, one in
each sea, and two autonomous cities in North Africa.
The Spanish mainland is bordered by the Mediterranean Sea to the south and east, by the
Cantabric Sea that includes the Bay of Biscay to the north, and by the Atlantic Ocean and
Portugal to the west. Spanish territory also includes the Balearic Islands in the
Mediterranean and the Canary Islands off the African coast. It shares land borders with
Portugal, France, Andorra, the British overseas territory of Gibraltar, and Morocco. It is
the largest of the three sovereign states that make up the Iberian Peninsula — the others
being Portugal and Andorra. With an area of 504,030 km², Spain is the second largest
country in Western Europe (behind France). Spain is a constitutional monarchy organized
as a parliamentary democracy, and has been a member of the European Union since
1986. It is a developed country with the ninth largest economy in the world and fifth
largest in the EU, based on nominal GDP.
Spain is divided into 17 autonomous communities (comunidades autónomas) and 2
autonomous cities (ciudades autónomas) - Ceuta and Melilla. These autonomous
communities are subdivided into 50 provinces (provincias). Historically, some provinces
are also divided into comarcas (roughly equivalent to a US "county" or an English
district). The lowest administrative division of Spain is the municipality (municipio)
(Figure 13).
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Figure 13: Map of Spain
Source: www.paradoxplace.com D A T A M O N I T O R
In 2007 Spain officially reached 45 million people registered at the Padrón municipal, an
official record analogous to the British Register office. Spain's population density, at
87.8/km² (220/mile2), is lower than that of most Western European countries and its
distribution along the country is very unequal. With the exception of the region
surrounding the capital, Madrid, the most populated areas lie around the coast.
The population of Spain doubled during the twentieth century, due to the spectacular
demographic boom by the 60's and early 70's. The pattern of growth was extremely
uneven due to large-scale internal migration from the rural interior to the industrial cities
during the 60's and 70's. No fewer than eleven of Spain's fifty provinces saw an absolute
133
decline in population over the century. Then, after the birth rate plunged in the 80's and
Spain's population became stalled, a new population increase started based initially in the
return of many Spanish who emigrated to other European countries during the 70's and,
more recently, it has been boosted by the large figures of foreign immigrants, mostly
from Latin America (38.75%), Eastern Europe (16.33%), North Africa (14.99%) and
Sub-Saharan Africa (4.08%).
In 2005, Spain instituted a 3-month amnesty program through which certain hitherto
undocumented aliens were granted legal residency. Also some important pockets of
population coming from other countries in the European Union are found (20.77% of the
foreign residents) , specially along the Mediterranean costas and Balearic islands, where
many choose to live their retirement or even telework. These are mostly English, French,
German, and Dutch from fellow EU countries and, from outside the EU, Norwegian. The
demographic distribution of Spain’s population in 2005 is given in the following figure
(Figure 14).
Figure 14: Demographic distribution of Spain’s population, 2005
Source: given in figure above D A T A M O N I T O R
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13.2. Spanish healthcare system
The 1986 General Health Care Act outlines the main principles of the Spanish National
Healthcare System (NHS). This system, created from the social security health services,
provides universal coverage with free access to healthcare, is publicly funded, mainly
through taxation, and has a regional organizational structure.
Public healthcare provision is coordinated by the Ministry of Health (MoH; Ministero de
Sanidad y Consumo). However, over the last 25 years, the Spanish healthcare system has
become increasingly devolved, with the 17 Autonomous Communities (ACs)
increasingly dominating healthcare provision. Regional healthcare funds are allocated
budgets following discussion between central and regional finance ministers. The
Ministry of Health has continued to govern the public healthcare service, although it is
relatively weak compared to other European central governance bodies. The
Interterritorial Council of the NHS (Consejo Interterritorial del Sistema Nacional de
Salud), composed of representatives of the autonomous communities and the State,
promotes the cohesion of the system (Health systems in transition, 2006). Given the wide
variation between the different regions of Spain, there is now considerable variation in
health policies from one region to another.
A key trend in the Spanish healthcare system is its decentralization, which was largely
completed in 2002, with the result that healthcare provision is now the primary
responsibility of Spanish ACs. The following figure (Figure 15) gives an overview of the
healthcare system in Spain (internal secondary research).
135
Figure 15: The Spanish healthcare system
Source: Lopez-Casasnovas et al., 2005 D A T A M O N I T O R
Access to healthcare is available for everyone, primarily via public health insurance, to a
lesser extent via private insurance or, in certain cases, through national healthcare
charities. The public compulsory healthcare insurance scheme covers 98% of the Spanish
population, which is part of the Social Security (Seguridad Social) system. The public
health insurance scheme covers all employees, the self-employed and their dependents,
the unemployed and pensioners. As in many other public healthcare systems, however,
patient waiting times can be quite long. As such, many Spaniards are willing to make out-
of-pocket payments or pay for private insurance to access services more quickly.
Approximately 15% of Spaniards have private health insurance, while a further 10% buy
supplemental coverage from private health provider. Under the public health insurance
system, patients are not required to make any payment towards the cost of medical care
and are reimbursed for a percentage of the cost of pharmaceuticals if they are prescribed
136
by a doctor working in the public sector. Patients must pay for drugs prescribed by a
private doctor, although private insurance may cover drug costs.
13.3. Healthcare insurance
Access to healthcare is available for everyone, primarily via public health insurance, to a
lesser extent via private insurance or, in certain cases, through national healthcare
charities. The public compulsory healthcare insurance scheme covers 98% of the Spanish
population, which is part of the Social Security (Seguridad Social) system. The public
health insurance scheme covers all employees, the self-employed and their dependents,
the unemployed and pensioners. As in many other public healthcare systems, however,
patient waiting times can be quite long. As such, many Spaniards are willing to make out-
of-pocket payments or pay for private insurance to access services more quickly.
Approximately 15% of Spaniards have private health insurance, while a further 10% buy
supplemental coverage from private health provider (Datamonitor DMHC2216, 2006).
Under the public health insurance system, patients are not required to make any payment
towards the cost of medical care and are reimbursed for a percentage of the cost of
pharmaceuticals if they are prescribed by a doctor working in the public sector. Patients
must pay for drugs prescribed by a private doctor, although private insurance may cover
drug costs.
13.4. Service delivery
Healthcare provision is managed within each region by the autonomous regional
governments’ relevant regional healthcare organization, such as the Catalan Health
Service (Servei Catala de la Salut – Catsalud) and the Andalucia Health Service (Servicio
Andaluz de Salud). It includes the provision of hospitals (public or private), including
university hospitals, private clinics, primary healthcare centers and outpatient centers,
office-based specialists, GPs, community nurses, ambulance services and dentists.
Benefits covered by the NHS include primary health care, which covers medical and
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pediatric health care, prevention of disease, health promotion and rehabilitation;
specialized health care in the form of outpatient and inpatient care, which covers all
medical and surgical specialties in acute care; and pharmaceutical benefits and
complementary benefits such as prostheses or orthopedic products. Dental care is heavily
underprovided in Spain.
In Italy, about 70% of hospitals are in the public sector and 30% in the private sector,
although this split can vary from region to region, with the percentage of private beds
being higher in prosperous regions such as Catalonia and lower in poorer regions such as
Andalucia and Extremadura. The majority of Spanish healthcare is delivered by public
healthcare providers. Almost 100% of primary care and the majority of hospitals are
owned and managed by the public sector.
Pursuant to the General Health Care Act (1986), primary health care (PHC) was given an
independent, reinforced status. The first contact point of the population with the health
system is the general practitioner, who acts as a gatekeeper. PHC coverage is rising with
the reformed network and, by 2001, was well above 90% in most autonomous
communities (WHO Regional Office for Europe, 2004).
Despite the political focus on PHC, the health system is still centered around hospitals.
Alongside the hospital system, there is an extensive network of outpatient ambulatory
centers. In the reformed model of provision, members of the specialist teams in clinical
departments rotate to cover outpatient care in ambulatory centers. Although waiting times
have decreased, they are still considerable in public health care provision.
13.5. Healthcare financing and expenditure
Total healthcare expenditure in Italy accounted for 8.2% of GDP in 2005. Spain is low in
terms of health spending per capita, with spending of $2,255 in 2005 (adjusted for
purchasing power parity) compared to other OECD countries. In 2005, 71.4% of health
spending was funded by public sources. The government expenditure on health accounted
138
for 14.7% of the total government expenditure in 2004 and the per capita government
expenditure on health amounted to $1,397.
The rise in pharmaceutical spending has been one of the factors behind the rise in total
health spending in Spain. In 2005, spending on pharmaceuticals accounted for 22.9% of
total health spending, up from 19.2% in 1995. But the one factor boosting cost
effectiveness is the relatively low price of drugs in Spain, compared to the rest of Europe,
and recent growth in pharmaceutical expenditure has been attributed to an increase in
prescription volume, rather than an increase in price per prescription (internal secondary
research). The following table (Table 26) shows the recent key health expenditure
indicators in the recent years.
Table 23: Spanish healthcare spending statistics
Indicator Value Total expenditure on health as percentage of gross domestic product 8.2% (2005) Public expenditure on health as percentage of total expenditure on health 71.4% (2005) Private expenditure on health as percentage of total expenditure on health 28.6% (2005) Out-of-pocket expenditure as percentage of private expenditure on health 81% (2004) Private prepaid plans as percentage of private expenditure on health 16.2% (2004) Per capita total expenditure on health (adjusted for purchasing power parity) $2,255 (2005)
Source: OECH Health Data, 2007 D A T A M O N I T O R
The health care system is financed out of general taxation such as value-added tax,
income tax and regionally raised taxes. Two autonomous communities, País Vasco and
Navarra, have gained relatively great fiscal autonomy. Private health care financing
complements public financing with out-of-pocket payments to the public system (such as
co-payments for pharmaceuticals) as well as the private sector (such as private outpatient
care) and contributions to voluntary insurance. Hospital payment mechanisms vary
among autonomous communities. Traditionally hospital expenditures were
retrospectively reimbursed, with no prior negotiation and no formal evaluation. During
the past two decades, the use of contract programs with prospective financing of target
139
activities increased, especially for private hospitals. Most physicians are employed by the
public sector and receive fixed salaries.
13.6. Resources
According to OECD Health data (2007), Spain had 3.8 practicing physicians per 1,000
population in 2005, above the OECD average of 3.0, despite the relatively low level of
health expenditure. On the other hand, there were 7.4 qualified nurses per 1,000
population in the same year.
There are approximately 800 hospitals in Spain. The number of acute care hospital beds
in Spain was 2.6 per 1,000 population in 2004. The number of hospital beds per capita in
Spain has fallen over time. This reduction has coincided with a reduction of average
length of stays in hospitals and an increase in the number of surgical procedures
performed on a same-day (or ambulatory) basis. The following table (Table 24) gives the
absolute number and density of physicians and nurses in the recent years. For a complete
review of the most up to date physician statistics, please refer to the Spanish physician
statistics section of this report.
Table 24: Spanish physician and nurse numbers Resource Indicator Value (year) Physicians (number) 135,300 (2003) Physicians (density per 1,000 population) 3.8 (2005) Nurses (number) 315,200 (2003) Nurses (density per 1,000 population) 7.4 (2005)
Source: OECD Healthcare Statistics, 2007 D A T A M O N I T O R
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13.7. Spanish pharmaceutical market
The Spanish pharmaceutical market is the seventh largest in the world, valued at $21
billion in 2006 (The pharmaceutical market: Spain, 2006, Espicom report). There are
currently around 270 pharmaceutical companies with production activity and
approximately 375 laboratories in Spain. Spanish pharmaceutical companies employ
about 39,000 people, which represents about 7% of the total European pharmaceutical
industry workforce (Outlook for pharmaceutical market in Spain looks strong, 2004,
Chiltern International report).
Spain’s pharmaceutical manufacturing sector is fragmented but advanced. It is almost
entirely concentrated in Barcelona and Madrid. Almirall Prodesfarma and Esteve are the
leading domestic producers, with sales valued at $1.2 billion and $1 billion, respectively,
in 2005 (The pharmaceutical market: Spain, 2006, Espicom report). It is estimated that
foreign companies now represent 75% of pharmaceutical producers in Spain. In 2002,
eight multinational companies featured among the top ten leading companies in Spain
and accounted for over 50% of the national market. The majority of sales of new
medicines in Spain have been in the oncology, cardiovascular and central nervous system
(CNS) categories.
The IMS Health market data reveal that between 2001 and 2002, the Spanish
pharmaceutical market grew by over 10% (Business briefing: Pharma outsourcing report,
Spain and the pharmaceutical industry, 2004). Although Spain has been considered as
one of the lower-priced European countries for pharmaceuticals, prices for innovative
new products are rapidly converging with those of neighboring countries. Industry figures
show that in 2002, a total of 185 new pharmaceutical products were launched in Spain, of
which generics represented 55% (Outlook for pharmaceutical market in Spain looks
strong, 2004, Chiltern International report). The average price of innovative therapeutic
products was $20, which was considerably higher than the average price for existing
medicines ($9.5) (Outlook for pharmaceutical market in Spain looks strong, 2004,
Chiltern International report).
141
Spain has one of the lowest generic use rates in the EU, with generics only accounting for
8.1% of the 5EU pharmaceutical markets in terms of volume. The generics market
accounted for 5.1% of 5EU pharmaceutical sales in 2004, resulting in a total value of
$715 million (The pharmaceutical market: Spain, 2006, Espicom report). Growth in the
generic sector has been impressive in recent years, although it still only accounts for
5.4% of the market by value and 9.4% by volume in 2005 (Spain and the pharmaceutical
industry, 2004, Business briefing: Pharma outsourcing report). There has been an
increase in the number of generic medicines available in Spanish hospitals with new data
showing that they accounted for 17.7% of all treatments authorized for use in hospitals in
October 2005 (The pharmaceutical market: Spain, 2006, Espicom report). Between 1999
and 2002, there was a 31.5% increase in research & development (R&D) activity for the
Spanish pharmaceutical industry. The following figure (Figure 16) shows the distribution
of funds for pharmaceuticals R&D in 2000.
Figure 16: Allocation of pharmaceutical R&D funds, 2000
Source: Business briefing: Pharma outsourcing report, Spain and the
pharmaceutical industry, 2004 D A T A M O N I T O R
Low prices make Spain a major source of parallel-trade drugs in the European Union.
Spain exported $3.6 billion of finished drugs in 2004, of which over 35% went to the UK
and Germany (The pharmaceutical market: Spain, 2006, Espicom report). The extension
of the public network, the transition from a social security system to a tax-funded system
142
and decentralization to the autonomous communities has reaped particularly favorable
results. The formal goal of shifting the focus of the health care system towards PHC has
not been accomplished yet. Challenges to be addressed include long waiting times,
information development, managerial autonomy and the expansion of social and
community care.
143
13.8. Bibliography
o World Health Organization (2007), World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=esp&indicators=selected&language=en> [Accessed October 2007].
o World Health Organization (2007), World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=esp&indicators=healthpersonnel> [Accessed October 2007].
o World Health Organization (2006), Health systems in transition 2006 [Internet].
WHO Regional Office for Europe on behalf of the European Observatory on
Health Systems and Policies. Available from:
<http://www.euro.who.int/Document/E89491.pdf> [Accessed October 2007].
o OECD data (2007), OECD Spain Health data 2007 [Internet] Available from:
<http://www.oecd.org/dataoecd/46/7/38980294.pdf> [Accessed October 2007].
o Chiltern International report (2004), Outlook for pharmaceutical market in Spain
looks strong [Internet]. Available from:
<http://www.medicalnewstoday.com/articles/6800.php> [Accessed October
2007].
o Datamonitor (2006), Pricing & Reimbursement in Europe: Can the drive for cost
effectiveness overcome cost containment?, September 2006, DMHC2238.
o Datamonitor (2006), Global Generics Guide: Part 2 - Benchmarking country
markets and strategic issues, June 2006, DMHC 2216.
o World Health Organization Regional Office for Europe, Highlights on health
(2004), [Internet]. Available from:
<http://www.euro.who.int/eprise/main/who/progs/chhspa/system/20050131_1>
[Accessed October 2007].
o Espicom report (2006), Spain generics market report, [Internet] Available from:
<https://www.espicom.com/Prodcat.nsf/Search/00000097?OpenDocument>
[Accessed October 2007].
144
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SPAIN 2006 Table No 1. Total Physicians by Specialty and Gender SPECIALTY TOTAL MALE % FEMALE %
TOTAL PHYSICIANS 149,942 82,702 55 67,240 45 Allergy / Immunology1 1,063 527 50 536 50
Anesthesiology / Intensive Care Medicine2 6,128 3,160 52 2,968 48 Cardiovascular Diseases 2,133 1,578 74 555 26 Cardiovascular Surgery and Angiology3 765 606 79 159 21 Dermatology 1,304 587 45 717 55 Endocrinology and Diabetes 899 450 50 450 50 Gastroenterology 1,812 1,160 64 652 36 General Physicians / General Practitioners / Family Doctors 76,180 39,880 52 36,300 48 General Surgery 3,797 2,848 75 949 25 Geriatric Medicine 737 339 46 398 54
Hematology 1,341 617 46 724 54 Internal Medicine 5,289 3,173 60 2,116 40 Medical Oncology 803 337 42 466 58 Nephrology 1,135 658 58 477 42 Neurology4 2,190 1,253 57 937 43 Neurosurgery 475 375 79 100 21 Nuclear Medicine 455 228 50 228 50 Obstetrics and Gynecology 5,098 2,651 52 2,447 48
Ophthalmology 3,032 1,819 60 1,213 40 Oral and Maxillofacial Surgery 418 322 77 96 23 Orthopedic Surgery and Traumatology 4,292 3,648 85 644 15 Otolaryngology 1,779 1,210 68 569 32 Pathology5 4,582 1,982 43 2,600 57 Pediatrics 8,145 3,584 44 4,561 56 Pediatric Surgery 308 219 71 89 29 Physical Medicine & Rehabilitation 1,313 591 45 722 55
Plastic Surgery 682 512 75 171 25 Psychiatry 3,563 1,924 54 1,639 46
145
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SPAIN 2006 Table No 1. Total Physicians by Specialty and Gender (Cont…) SPECIALTY TOTAL MALE % FEMALE %
Public Health / Preventive Medicine / Occupational Medicine 1,562 890 57 672 43
Pulmonology 1,937 1,182 61 755 39 Radiation Oncology 452 226 50 226 50 Radiology 2,941 1,647 56 1,294 44 Rheumatology 966 551 57 415 43 Thoracic Surgery 178 141 79 37 21 Urology 1,895 1,706 90 190 10 Other specialties 293 123 42 170 58 1 Allergy + Immunology 2 Anesthesiology + Intensive Medicine 3 Cardiovascular surgery + Angiology and Surgery 4 Neurology + Clinical Neurophysiology 5 Anatomical Pathology + Clinical Analysis + Clinical Biochemistry + Microbiology
Note: General Practitioners statistics is of the year 2004 Source:
1) CESM (2005) Physicians Demography [internet], CESM. Available from: <http://www.cesm.org/nueva/fundaciondemogr/Publicaciones/AbstractPhysicDemogr.htm> [Accessed October 2007] 2) MSC (2007) OFERTA Y NECESIDAD DE MEDICOS ESPECIALISTAS EN ESPANA [internet], MSC. Available from: <http://www.msc.es/novedades/docs/necesidadesEspeciales06_30.pdf>
[Accessed October 2007]
146
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SPAIN 2006 Table No 2. Total Physicians by Specialty and Age SPECIALTY TOTAL UNDER 36 36-45 46-55 56-65 65 AND OVER
TOTAL PHYSICIANS 149,942 37,962 71,641 30,263 7,673 2,403 Allergy / Immunology1 1,063 478 466 90 27 2 Anesthesiology / Intensive Care Medicine2 6,128 2,023 1,774 1,815 430 85 Cardiovascular Diseases 2,133 691 473 676 227 66 Cardiovascular Surgery and Angiology3 765 287 201 191 65 20 Dermatology 1,304 431 478 305 72 18 Endocrinology and Diabetes 899 259 322 208 87 23 Gastroenterology 1,812 653 454 512 148 45 General Physicians / General Practitioners / Family Doctors 76,180 14,687 48,240 10,519 1,896 840
General Surgery 3,797 923 1,170 1,297 306 101 Geriatric Medicine 737 458 189 62 14 14 Hematology 1,341 473 340 419 101 8 Internal Medicine 5,289 1,263 1,454 1,859 577 136
Medical Oncology 803 516 205 72 9 0 Nephrology 1,135 371 367 369 28 0 Neurology4 2,190 999 616 432 114 29 Neurosurgery 475 127 80 215 38 15 Nuclear Medicine 455 200 185 62 7 0 Obstetrics and Gynecology 5,098 1,646 1,377 1,409 542 123 Ophthalmology 3,032 938 1,122 747 172 53 Oral and Maxillofacial Surgery 418 222 125 46 22 2
Orthopedic Surgery and Traumatology 4,292 1,397 1,086 1,356 369 85 Otolaryngology 1,779 530 627 470 129 24 Pathology5 4,582 1,177 1,905 1,107 334 59 Pediatrics 8,145 2,272 2,149 2,242 1,054 428 Pediatric Surgery 308 51 89 132 30 6 Physical Medicine & Rehabilitation 1,313 417 501 323 66 5 Plastic Surgery 682 253 213 167 46 2 Psychiatry 3,563 1,196 1,150 915 264 38
147
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SPAIN 2006 Table No 2. Total Physicians by Specialty and Age (Cont…) SPECIALTY TOTAL UNDER 36 36-45 46-55 56-65 65 AND OVER Public Health / Preventive Medicine / Occupational Medicine 1,562 349 976 171 42 24
Pulmonology 1,937 655 640 449 142 51 Radiation Oncology 452 226 166 50 9 2 Radiology 2,941 943 1,171 673 129 26 Rheumatology 966 277 401 228 49 11
Thoracic Surgery 178 50 56 56 11 5 Urology 1,895 496 676 569 102 52 Other Specialties 293 28 197 50 14 4 1 Allergy + Immunology 2 Anesthesiology + Intensive Medicine 3 Cardiovascular surgery + Angiology and Surgery 4 Neurology + Clinical Neurophysiology 5 Anatomical Pathology + Clinical Analysis + Clinical Biochemistry + Microbiology
Note:
1) General Practitioners statistics is of the year 2004. 2) It was assumed that the age break up within the specialties to remain similar to that of the earlier available statistics (year 1999).
Source:
1) CESM (2005) Physicians Demography [internet], CESM. Available from: <http://www.cesm.org/nueva/fundaciondemogr/Publicaciones/AbstractPhysicDemogr.htm> [Accessed October 2007] 2) MSC (2007) OFERTA Y NECESIDAD DE MEDICOS ESPECIALISTAS EN ESPANA [internet], MSC. Available from: <http://www.msc.es/novedades/docs/necesidadesEspeciales06_30.pdf>
[Accessed October 2007]
148
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SPAIN 2006 Table No.3a Total Physicians by Gender and Major Professional Activity, 1999
PROFESSIONAL ACTIVITY TOTAL MALE % FEMALE %
Total 130,204 70,128 53.9 60,076 46 Total Private Sector 15,774 9,766 61.9 6,008 38 General Consultation in Public Sector 33,034 19,996 60.5 13,038 40 Specialist Consultation in Public Sector 24,944 16,722 67 8,222 33 Other Activities in Public Sector 13,228 6,848 51.8 6,380 48 Residence (in training) 19,128 7,366 38.5 11,762 62 No Medical Activities / Unemployed Physicians 24,096 9,430 39.1 14,666 60
Table No.3b Total Physicians by Age and Major Professional Activity, 1999
PROFESSIONAL ACTIVITY TOTAL <36 36-45 46-55 56-65 >65
Total 130,204 43,389 60,779 19,757 4,720 1,559 Total Private Sector 15,774 1,490 11,220 2,419 498 147 General Consultation in Public Sector 33,034 2,618 21,788 6,472 1,351 805 Specialist Consultation in Public Sector 24,944 1,243 11,856 8,852 2,493 500 Other Activities in Public Sector 13,228 5,602 6,534 906 156 30 Residence (in training) 19,128 17,587 1,541 0 0 0 No Medical Activities / Unemployed Physicians 24,096 14,849 7,840 1,108 222 77
Source: Doctor Universe Statistics in Major Markets, December 2003
149
14. UK
150
14.1. Introduction to the UK
The United Kingdom (UK) of Great Britain and Northern Ireland is in Western Europe. It
comprises the island of Great Britain (most of England, Scotland and Wales) and the
north-eastern one-sixth of the island of Ireland (Northern Ireland) , together with many
smaller islands. The UK has a total area of approximately 245,000 square kilometers
(94,600 square miles). The UK lies between the North Atlantic Ocean and the North Sea,
and comes within 35 kilometers (22 miles) of the north-west coast of France, from which
it is separated by the English Channel. Northern Ireland shares a 360 kilometers (224
miles) land boundary with the Republic of Ireland (Figure 17).
Figure 17: Map of the UK
Source: www.kmike.com D A T A M O N I T O R
151
At the April 2001 UK census, the UK’s population was 58.8 million, the third largest in
the European Union (behind Germany and France), the fifth largest in the
Commonwealth and the twenty-first largest in the world. In August 2006 it was
confirmed that the UK's population had reached 60 million, then rapidly increased to 60.2
million, largely from net immigration, but also because of a rising birth rate and
increasing life expectancy.
The UK's overall population density is one of the highest in the world. About a quarter of
the population lives in England's prosperous south-east and is predominantly urban and
suburban, with an estimated 7.5 million in the capital of London. In 2006 the UK's total
fertility rate (TFR) was 1.86 children per woman, below the replacement rate of 2.1. In
2001, the TFR was at a record low of 1.63, but it has increased each year since, and will
continue to do so as the share of births from immigrant mothers continues to prod the
fertility rate. The TFR was considerably higher during the 1960s 'baby boom', peaking at
2.95 children per woman in 1964.
14.2. The UK healthcare system
The UK has devolved responsibility for healthcare to its constituent countries. They
mainly fund health care through national taxation, deliver services through public
providers and have devolved purchasing responsibilities to local bodies: primary care
trusts (PCTs) in England, primary care partnerships in Northern Ireland, health boards in
Scotland and local health boards (LHBs) in Wales.
Coverage is available to 100% of the population. All legal residents of the UK, residents
of the European Economic Area and citizens of other countries with which the UK has
reciprocal agreements are covered under the United Kingdom National Health Service
(NHS). Therefore, the uptake of private medical insurance is quite low at 11.5% of the
population in 2001.
152
The organizational structures for health service administration and delivery vary between
United Kingdom countries. In England, for example, personnel with public health
functions can be found in the central and regional departments of Health, the strategic
health authorities and the PCTs. In Wales, a national public health service has been
established to provide services and support to the LHBs, other NHS organizations and
local authorities.
There are considerable differences in health system across the United Kingdom. In
Scotland, major differences include the funding of personal as well as nursing care for
people in long-term care, and the decision not only to reject foundation trusts but also to
abolish hospital trusts, reorganize primary care and develop community health
partnerships. Northern Ireland, in contrast to the rest of the United Kingdom, has always
had integrated health and social care services.
In Wales, the Welsh Assembly Government has reformed the NHS by setting up LHBs to
plan and commission services to meet most health needs, while an all-Wales body
commissions specialist hospital services. Developments include adjusting the way
resources are allocated to the NHS to take account of the needs of disadvantaged areas,
and to address inequities in access to health services. The Assembly Government has also
announced the phased elimination of co-payments for prescriptions for all, regardless of
income, over a five-year period beginning in 2004. The figure below (Figure 18) gives an
overview of the healthcare system in the UK (internal secondary research).
153
Figure 18: Structure of the UK health service
Source: www.bized.co.uk D A T A M O N I T O R
14.3. Healthcare insurance
The vast majority of healthcare in the UK is not only paid for by general taxation, but
also delivered by a government-owned system. The UK healthcare system is primarily a
public system, of which four-fifths of the funding comes from taxation, 12% is funded
with national insurance, with patient co-payments funding the remaining 8% (internal
secondary research). Coverage is universal and services are free at the point of delivery.
Private healthcare is entirely separate from the state system, paid for separately and using
different facilities, although senior specialist physicians can work in both sectors.
Private healthcare is restricted to a relatively low percentage of UK citizens who can
afford it. The percentage of the UK population covered by private healthcare has risen
over the last 20 years, from 5% of the population in 1980 to 12.7% by 2003. Despite the
154
relatively low private insurance coverage compared to countries such as the US (where
private healthcare covers approximately two-thirds of the population), there is an
increasing role for private healthcare in the UK, in the form of healthcare financing and
delivery. Private contractors have been used to provide hospital care in both the UK and
in Europe to cut waiting list time. The exchange between private and public healthcare
goes both ways, as private healthcare plans also pay to use NHS hospitals.
14.4. Service delivery
The UK healthcare system is relatively complex, with a range of different trusts and
authorities delivering and impacting on healthcare provision. In the United Kingdom,
GPs in group practices (with an average of three per practice) provide primary care. In
England in 2002, a GP served about 1800 members of the local community. There are
also a small number of NHS walk-in clinics. GPs act as gatekeepers in the system, and a
referral is required to gain access to specialist services. In 2004, 209 NHS trusts provided
secondary care in the English NHS, and 23 mental health trusts provided specialist
mental health services in hospitals and the community. There are about 240 private acute
hospitals, accounting for less than 5% of total beds.
Improving the efficiency, responsiveness and equity of the system has recently become
an important issue. Measures have been introduced to reach particular aims, including
reducing waiting lists, improving the quality of care provision, increasing funding and
staff numbers, encouraging innovation and extending patient choice.
14.5. Healthcare financing and expenditure
Total health spending accounted for 8.3% of GDP in the UK in 2005. Per capita spending
on health in the United Kingdom was 2724 USD in 2005 (adjusted for purchasing power
parity). Health spending per capita in the United Kingdom remains much lower. The
share of public funding of total expenditure was 86.3% in 2004, reflecting the UK
government’s commitment to increase public spending on health. Private share of total
155
healthcare expenditure is relatively low, at 13.7%. Table 26 shows the key health
expenditure indicators in the recent years.
Table 25: Key health expenditure indicators
Indicator Value (year) Total expenditure on health as percentage of gross domestic product 8.%3 (2005) Public expenditure on health as percentage of total expenditure on health 86.3% (2004) Private expenditure on health as percentage of total expenditure on health 13.7% (2004) Out-of-pocket expenditure as percentage of private expenditure on health 91.8% (2004) Private prepaid plans as percentage of private expenditure on health 8.2% (2004) Per capita total expenditure on health (adjusted for purchasing power parity) $2,724 (2005)
Source: OECD Health Data, 2007 D A T A M O N I T O R
The NHS is mainly funded through general taxation: direct taxes, value-added tax and
employee income contributions. Local taxation provides further funding for social
services. Private funding can be broken down into out-of-pocket payments for
prescription drugs, ophthalmic and dental services and private medical insurance
premiums. Services are mostly free at the point of use.
In England, budgets for health care are set every three years through negotiations
between the Chancellor of the Exchequer and Department of Health. In the rest of the
United Kingdom, the devolved administrations set budgets separately. LHBs and PCTs,
covering populations of 50, 000–250, 000, are the main purchasers of health services. The
central Government uses a weighted capitation formula to allocate funding to them.
General practitioners (GPs) are self employed. On 1 April 2004, remuneration of their
services moved from a system mainly based on capitation and fixed allowances to one
that combines capitation and quality points. With most of the population concentrated in
urban areas, there are problems with access to and sustainability of services in remote and
rural areas. Hospitals receive activity-based and contract financing. Hospital staffs are
mainly salaried, but consultants are also permitted to earn money in the private sector.
156
14.6. Resources
Following a perceived shortage of health professionals in the UK, there has, over recent
years, been a determined and active campaign to increase numbers. Latest figures show
that in 2005, the UK had 2.4 practicing physicians per 1,000 population, up from 1.9
doctors per 1,000 population in 1998. Similarly, there has been a notable increase in the
number of nurses in the UK in recent years, after a period of relative stability. In 2005,
there were 9.1 nurses per 1,000 population in the UK, compared with 8.0 in 1998.
The number of acute care hospital beds in the UK was 3.1 per 1 000 population in 2005.
In line with many OECD countries, the number of hospital beds per capita in the UK has
fallen gradually over the past decade. This decline has coincided with a reduction of
average length of stays in hospitals and an increase in the number of surgical procedures
performed on a same-day (or ambulatory) basis. The following table (Table 26) shows
the absolute and density of physicians and nurses in the recent years.
Table 26: UK physicians and nurses, 2005
Resource Indicator Value (year) Physicians (number) n/a Physicians (density per 1 000 population) 2.4 (2005) Nurses (number) n/a Nurses (density per 1 000 population) 1.9 (2005) n/a – not available Source: OECD Health Data, 2007 D A T A M O N I T O R
14.7. The UK pharmaceutical market
The UK is the world’s fifth largest pharmaceutical market and the third largest in the
European Union. Sales declined by 2% in 2005 to reach $22.1 billion, or $384 per person,
($19.5 billion / $328) (internal secondary research). Two major factors contributed to the
decline: first, manufacturers were required to reduce prices by 7% as a result of the
pricing agreement signed in 2005; second, several major products lost patent protection
157
and were quickly exposed to generic penetration. With 89% of direct payments and a
further 6% derived from co-payments, the NHS is very nearly the sole purchaser of
prescription pharmaceuticals in the UK. Only 5% of industry turnover is generated by
private, non-NHS purchases. The following table (Table 27) shows the retail sales by
therapeutic category in 2005.
Table 27: UK retail sales by therapeutic category, 2005 Category Sales $m 2005 % Change Cardiovascular 3,308 -16% Central Nervous System 3,213 4% Alimentary/ Met. 2,335 3% Respiratory 1,754 -1% Anti- Infectives 488 -5% Musculoskeletal 830 -14% Genitourinary 760 0% Cytostatics 435 -11% Blood Agents 497 17% Dermatologicals 535 1% Sensory Organs 270 4% Diagnostic Agents 276 8% Systemic Hormones 181 9% Miscellaneous 26 9% Hospital Solutions 15 4% Parasitology 62 14% Total 14,985 -3%
Source: internal secondary research D A T A M O N I T O R
The UK has an extremely high prevalence of generics in the market. As shown in table
34, over half of prescriptions are dispensed for generics. By value, branded products
represented 79.9% of the market in 2004, a decline from 83% in 2003. The following
table (Table 28) shows the trend in market value for branded and generic drugs.
158
Table 28: Evolution of generic / brand share of market value in the UK, 2000-2004 2000 2001 2002 2003 2004 Generics 13.8% 11.1% 13.3% 17% 20.1% Brands 86.2% 88.9% 86.7% 83% 79.9%
Source: internal secondary research D A T A M O N I T O R
The British pharmaceutical industry spent 24% of sales, or $6.6 billion, on R&D in 2004.
This is essentially unchanged from $6.7 billion in 2003. As a high price EU market, the
UK is a major destination for parallel imports. However, the growth rates of parallel
imports fell during 2004 to 11%, down from 44% in 2001. Pharmaceuticals are one of
Britain’s leading manufacturing sectors, bringing in a trade surplus of $7 billion in 2004.
And the industry is a major employer, with around 73, 000 people employed directly
(http://www.abpi.org.uk/). The value of UK pharmaceutical exports in 2005 was $252.6
billion, more than $343,704 per employee.
Prescription medicines are the subject of Government controls and intensive competition.
Research and development lies at the heart of the pharmaceutical industry. It invests 30
per cent of its sales in research, and a quarter of the entire research expenditure by the
UK manufacturing sector is funded or carried out by the pharmaceutical sector. Research
and development expenditure by the pharmaceutical industry in Britain amounts to more
than $6.2 billion, or around $18.6 million a day.
Of the major medicines sold in the UK, around half were developed in British
laboratories. More than 825 million prescriptions are dispensed every year, at an average
cost of around $22.7 each. The UK is one of the most developed generics markets in
Europe. According to the European Generics Association (EGA), generics accounted for
21% of the total UK pharmaceutical market in terms of value and 49% of volume in
2004.
159
14.8. Bibliography
o World Health Organization (2007), World health statistics [Internet]. Available
from:
<http://www.who.int/whosis/database/core/core_select_process.cfm?country=gbr
&indicators=selected&language=en> [Accessed October 2007].
o Datamonitor (2006), Global Generics Guide: Part 2 - Benchmarking country
markets and strategic issues, June 2006, DMHC 2216.
o OECD data (2007), OECD United Kingdom Health data 2007 [Internet] Available
from: < http://www.oecd.org/dataoecd/46/4/38980557.pdf> [Accessed October
2007].
o World Health Organization (1999), Health systems in transition 1999 [Internet].
WHO Regional Office for Europe on behalf of the European Observatory on
Health Systems and Policies, 2004. Available from:
<http://www.euro.who.int/document/e68283.pdf> [Accessed October 2007].
o VOI Consulting (2006), PharmaHandbook: A Guide to the International
Pharmaceutical Industry 2006.
160
ENGLAND
161
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006 Table No 1. Total Physicians by Specialty and Gender SPECIALTY TOTAL MALE % FEMALE %
TOTAL PHYSICIANS 93,320 57,608 62 35,712 38 Accident & Emergency 4,714 2,950 63 1,764 37
Anesthesiology 10,281 6,780 66 3,501 34 Clinical oncology 1,052 536 51 516 49 Dental group 2,380 1,480 62 900 38 Endodontics 10 5 50 5 50 Oral & Maxillofacial Surgery 1,143 779 68 364 32 Oral Surgery 147 79 54 68 46 Orthodontics 544 303 56 241 44
Pediatric Dentistry 81 34 42 47 58 Periodontics 20 13 65 7 35 Prosthodontics 14 11 79 3 21 Restorative Dentistry 223 142 64 81 36 Surgical Dentistry 11 7 64 4 36 Additional Dental Medicine Specialties 187 107 57 80 43
General Medical Practitioners (excluding GP registrars and retainers) 33,091 19,541 59 13,550 41 General medicine group 23,399 14,043 60 9,356 40 Allergy 24 14 58 10 42 Audiological Medicine 72 35 49 37 51 Cardiology 2,056 1,626 79 430 21 Clinical Genetics 211 65 31 146 69 Clinical Neurophysiology 102 79 77 23 23 Clinical Pharmacology and Therapeutics 188 124 66 64 34 Dermatology 1,129 508 45 621 55 Endocrinology and Diabetes Mellitus 1,223 799 65 424 35 Gastroenterology 1,538 1,150 75 388 25
General (Internal) Medicine 5,767 3,125 54 2,642 46 Genito-urinary Medicine 969 408 42 561 58
162
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006 Table No 1. Total Physicians by Specialty and Gender (Cont…) SPECIALTY TOTAL MALE % FEMALE %
Geriatric Medicine 2,956 1,772 60 1,184 40
Infectious Diseases 298 189 63 109 37 Medical Oncology 601 329 55 272 45 Medical Ophthalmology 25 18 72 7 28 Neurology 1,012 738 73 274 27 Occupational Health 202 125 62 77 38 Palliative Medicine 389 108 28 281 72 Rehabilitation Medicine 227 156 69 71 31 Renal Medicine 927 608 66 319 34
Respiratory Medicine 1,451 957 66 494 34 Rheumatology 992 612 62 380 38 Sports and Exercise Medicine 9 4 44 5 56 Other 1,031 494 48 537 52
Obstetrics & Gynecology 4,958 2,296 46 2,662 54 Pediatric Group 7,039 3,171 45 3,868 55 Pediatric Cardiology 124 83 67 41 33 Pediatrics 6,915 3,088 45 3,827 55
Pathology Group 3,956 2,182 55 1,774 45 Chemical Pathology 251 165 66 86 34 Clinical Cytogenetics and Molecular Genetics 24 10 42 14 58 Hematology 1,308 707 54 601 46 Histopathology 1,643 903 55 740 45 Immunology 103 65 63 38 37 Medical Microbiology & Virology 627 332 53 295 47
PHM & CHS Group 3,283 1,248 38 2,035 62 Dental Public Health 1,529 527 34 1,002 66
Public Health Medicine 1,754 721 41 1,033 59
163
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006 Table No 1. Total Physicians by Specialty and Gender (Cont…) SPECIALTY TOTAL MALE % FEMALE %
Psychiatry Group 9,629 5,590 58 4,039 42 Child and Adolescent Psychiatry 1,060 455 43 605 57 Forensic Psychiatry 519 342 66 177 34 General Psychiatry 6,090 3,654 60 2,436 40 Learning Disabilities 531 330 62 201 38 Old age Psychiatry 1,271 721 57 550 43 Psychotherapy 158 88 56 70 44
Radiology Group 3,204 2,084 65 1,120 35 Clinical Radiology 3,129 2,034 65 1,095 35
Nuclear Medicine 75 50 67 25 33
Surgical Group 19,425 15,248 78 4,177 22 Cardiothoracic Surgery 717 632 88 85 12 General Surgery 6,591 4,752 72 1,839 28 Neurosurgery 553 481 87 72 13 Ophthalmology 2,293 1,576 69 717 31 Otolaryngology 1,614 1,308 81 306 19 Pediatric Surgery 304 183 60 121 40 Plastic Surgery 780 621 80 159 20 Trauma and Orthopedic Surgery 5,163 4,533 88 630 12 Urology 1,410 1,162 82 248 18
Source: IC (2007) NHS Hospital and Community Health Services: Medical and Dental Workforce Census England - 30 September 2006 - Detailed Results [internet], IC. Available from: <http://www.ic.nhs.uk/webfiles/publications/nhsstaff2006/med/Medical%20and%20Dental%20Detailed%20Results%202006.pdf> [Accessed September 2007]
164
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006 Table No 2. Total Physicians by Specialty and Age
SPECIALTY TOTAL UNDER 30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 AND
OVER UN
KNOWN TOTAL PHYSICIANS 93,320 21,450 17,265 14,131 12,378 10,067 7,849 6,247 3,138 661 134 -
Accident & Emergency 4,714 1,948 997 648 423 255 183 156 85 19 - Anesthesiology 10,281 1,473 2,143 1,799 1,625 1,251 901 694 336 55 4 Clinical Oncology 1,052 176 238 205 135 104 75 80 32 5 2 Dental Group 2,380 524 372 361 309 288 222 179 98 24 3 Endodontics 10 - 4 3 3 - - - - - - Oral & Maxillofacial Surgery 1,143 301 163 180 149 115 94 86 50 5 -
Oral Surgery 147 42 21 23 18 16 15 7 5 - - Orthodontics 544 57 112 72 86 83 60 44 22 6 2
Pediatric Dentistry 81 13 16 14 13 7 6 6 4 2 - Periodontics 20 1 3 4 2 1 2 5 1 1 - Prosthodontics 14 1 2 1 3 4 1 1 - 1 - Restorative Dentistry 223 50 26 34 20 39 32 11 7 4 - Surgical Dentistry 11 1 3 1 1 3 1 - 1 - - Additional Dental Medicine Specialties 187 58 22 29 14 20 11 19 8 5 1
General Medical practitioners (excluding GP registrars and retainers)
33,091 527 3,569 4,529 5,979 6,303 5,124 4,148 1,972 719 220 1
General medicine group 23,399 7,382 3,953 3,253 2,735 2,030 1,665 1,443 726 165 47 Allergy 24 2 2 5 4 1 3 2 2 2 1 Audiological Medicine 72 3 8 9 15 6 8 14 8 - 1 Cardiology 2,056 447 413 366 321 198 143 100 52 12 4
Clinical Genetics 211 6 30 46 39 39 28 16 6 - 1 Clinical Neurophysiology 102 - 6 12 20 13 22 18 6 4 1 Clinical Pharmacology and Therapeutics 188 71 32 28 13 12 8 14 6 3 1
165
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006 Table No 2. Total Physicians by Specialty and Age (Cont…)
SPECIALTY TOTAL UNDER 30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 AND
OVER UN
KNOWN Dermatology 1,129 70 189 202 182 160 133 121 52 15 5 Endocrinology and Diabetes Mellitus 1,223 219 190 247 182 116 99 105 53 7 5
Gastroenterology 1,538 330 293 274 253 145 91 90 52 9 1 Genito-urinary Medicine 969 103 143 128 158 143 121 90 58 20 5 Geriatric Medicine 2,956 958 462 387 283 258 277 204 105 21 1 Infectious Diseases 298 73 62 46 37 35 26 9 8 1 1 Medical Oncology 601 113 135 120 77 51 39 43 20 2 1 Medical Ophthalmology 25 1 2 5 3 4 2 5 2 - 1 Neurology 1,012 173 144 208 152 118 83 88 31 10 5
Occupational Health 202 6 17 22 47 32 35 20 22 1 - Palliative Medicine 389 48 94 47 72 48 48 19 10 3 - Rehabilitation Medicine 227 31 22 35 34 27 31 30 14 2 1 Renal Medicine 927 253 187 146 133 91 56 33 25 2 1 Respiratory Medicine 1,451 362 303 241 166 121 99 107 46 4 2 Rheumatology 992 128 148 172 157 122 91 107 49 14 4 Sports and Exercise Medicine 9 2 1 1 1 - - 2 2 - -
Other 6,798 3,983 1,070 506 386 290 222 206 97 33 5
Obstetrics & Gynecology 4,958 1,005 914 838 754 582 395 296 152 20 2 Pediatric Group 7,039 1,665 1,556 1,062 862 683 532 442 198 36 3 Pediatric Cardiology 124 19 28 17 16 21 9 7 3 3 1 Pediatrics 6,915 1,646 1,528 1,045 846 662 523 435 195 33 2
Pathology Group 3,956 371 650 591 574 598 551 386 179 50 6 Chemical Pathology 251 25 29 25 31 35 49 38 15 4 - Clinical Cytogenetics and Molecular Genetics 24 1 6 2 4 5 3 2 1 - -
Hematology 1,308 180 227 184 161 168 166 142 61 17 2 Histopathology 1,643 121 289 275 250 260 223 124 75 23 3
166
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006 Table No 2. Total Physicians by Specialty and Age (Cont…)
SPECIALTY TOTAL UNDER 30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 AND
OVER UN
KNOWN Immunology 103 2 19 17 18 18 11 9 8 1 - Medical Microbiology & Virology 627 42 80 88 110 112 99 71 19 5 1
PHM & CHS Group 3,283 256 326 366 476 627 543 406 225 44 14 Dental Public Health 1,529 158 201 173 215 276 239 168 81 14 4 Public Health Medicine 1,754 98 125 193 261 351 304 238 144 30 10
Psychiatry Group 9,629 1,364 1,909 1,583 1,426 1,203 925 716 375 100 28 Child and Adolescent Psychiatry 1,060 90 171 178 190 156 130 87 46 11 1
Forensic Psychiatry 519 62 103 107 100 64 38 28 15 1 1 General Psychiatry 6,090 1,019 1,321 973 843 704 526 411 219 54 20 Learning Disabilities 531 44 76 79 74 79 67 61 36 12 3 Old age Psychiatry 1,271 143 221 220 197 181 135 107 45 20 2 Psychotherapy 158 6 17 26 22 19 29 22 14 2 1
Radiology Group 3,204 196 720 560 468 455 375 262 125 40 3 Clinical Radiology 3,129 189 711 548 458 442 367 254 121 36 3 Nuclear Medicine 75 7 9 12 10 13 8 8 4 4 -
Surgical Group 19,425 5,090 3,487 2,865 2,591 1,991 1,482 1,187 607 103 22 Cardiothoracic Surgery 717 137 129 140 116 74 55 46 14 5 1 General Surgery 6,591 2,527 953 792 772 571 432 351 161 28 4 Neurosurgery 553 124 132 100 76 54 27 21 14 4 1 Ophthalmology 2,293 232 395 387 390 307 261 197 98 20 6 Otolaryngology 1,614 312 281 230 224 180 151 124 88 20 4
Pediatric Surgery 304 79 58 48 41 23 29 15 8 3 - Plastic Surgery 780 159 189 123 129 85 45 35 13 1 1 Trauma and Orthopedic Surgery 5,163 1,192 1,115 833 662 522 345 307 164 18 5
Urology 1,410 328 235 212 181 175 137 91 47 4 -
Note: 1) ' - ' denotes zero; 2) ' 0 ' denotes less than one, more than zero Source: The information centre, National Health Service, Department of Health, 2006 [Accessed October 2007].
167
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006 Table No 3. Medical Staff by specialty and Grade
SPECIALTY TOTAL
CONSULTANT (INCLUDING DIRECTOR OF PUBLIC HEALTH)
ASSOCIATE SPECIALIST
STAFF GRADE
REGISTRAR GROUP
SENIOR HOUSE
OFFICER
FOUNDATION YEAR 2
HOUSE OFFICER &
FOUNDATION PROGRAM
YEAR 1
HOSPITAL PRACTITIONER/
CLINICAL ASSISTANT
OTHER STAFF
TOTAL PHYSICIANS 93,320 32,874 2,830 5,937 18,808 18,863 3,693 4,905 3,522 1,888
Accident & Emergency 4,714 725 110 536 802 1,607 714 96 123 1
Anesthesiology 10,281 4,698 275 782 2,283 1,927 103 121 82 10 Clinical Oncology 1,052 482 17 43 302 142 27 15 24 - Dental Group 2,380 692 115 217 345 486 3 26 442 54 Endodontics 10 1 - - 1 - - - 4 4 Oral & Maxillofacial Surgery
1,143 306 54 164 118 370 3 1 121 6
Oral Surgery 147 28 8 18 13 42 - - 35 3 Orthodontics 544 189 21 12 139 9 - 1 162 11 Pediatric Dentistry 81 31 3 3 18 6 - - 15 5 Periodontics 20 8 1 - 1 2 - - 2 6
Prosthodontics 14 2 - 2 1 - - - 8 1 Restorative Dentistry 223 82 6 7 37 35 - 1 52 3
Surgical Dentistry 11 - 3 2 1 - - 1 2 2 Additional Dental Medicine Specialties
187 45 19 9 16 22 - 22 41 13
General medicine Group 23,399 7,277 453 908 4,454 4,728 1,470 2,358 1,724 27
Allergy 24 9 - 2 5 - 1 - 7 - Audiological Medicine 72 40 7 2 19 3 1 - - -
Cardiology 2,056 752 34 89 591 307 64 96 123 -
Clinical Genetics 211 132 13 5 56 1 - - 4 -
168
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006 Table No 3. Medical Staff by specialty and Grade (Cont…)
SPECIALTY TOTAL
CONSULTANT (INCLUDING DIRECTOR OF PUBLIC HEALTH)
ASSOCIATE SPECIALIST
STAFF GRADE
REGISTRAR GROUP
SENIOR HOUSE
OFFICER
FOUNDATION YEAR 2
HOUSE OFFICER &
FOUNDATION PROGRAM
YEAR 1
HOSPITAL PRACTITIONER/
CLINICAL ASSISTANT
OTHER STAFF
Clinical Neurophysiology 102 81 - 1 17 1 - - 2 -
Clinical Pharmacology and Therapeutics
188 54 3 2 54 33 14 23 5 -
Dermatology 1,129 454 67 46 188 56 9 4 305 - Endocrinology and Diabetes Mellitus 1,223 506 19 25 343 117 32 69 112 -
Gastroenterology 1,538 639 22 26 457 163 44 108 79 - General (Internal) Medicine 5,767 521 56 207 285 2,228 642 1,484 336 8
Genito-urinary Medicine 969 348 59 97 133 87 25 4 211 5
Geriatric Medicine 2,956 909 52 178 501 711 165 270 169 1 Infectious Diseases 298 116 - 6 86 62 14 9 5 -
Medical Oncology 601 233 9 28 184 93 16 15 23 - Medical Ophthalmology 25 13 2 1 4 4 - - 1 -
Neurology 1,012 506 16 20 231 163 28 8 40 - Occupational Health 202 95 8 3 48 5 - 1 31 11
Palliative Medicine 389 185 8 28 83 28 19 3 33 2
Rehabilitation Medicine 227 106 7 20 45 28 8 8 5 -
Renal Medicine 927 347 17 17 291 182 20 46 7 - Respiratory Medicine 1,451 583 12 15 467 174 35 127 38 -
Rheumatology 992 511 15 26 219 75 8 28 110 -
169
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006 Table No 3. Medical Staff by specialty and Grade (Cont…)
SPECIALTY TOTAL
CONSULTANT (INCLUDING DIRECTOR OF PUBLIC HEALTH)
ASSOCIATE SPECIALIST
STAFF GRADE
REGISTRAR GROUP
SENIOR HOUSE
OFFICER
FOUNDATION YEAR 2
HOUSE OFFICER &
FOUNDATION PROGRAM
YEAR 1
HOSPITAL PRACTITIONER/
CLINICAL ASSISTANT
OTHER STAFF
Sports and Exercise Medicine 9 4 1 - 2 - - 2 - -
Other 1,031 133 26 64 145 207 325 53 78 - Obstetrics & Gynecology 4,958 1,506 125 280 1,328 1,318 184 58 142 17
Pediatric Group 7,039 2,154 287 530 1,736 1,935 204 129 47 17 Pediatric Cardiology 124 63 - - 36 25 - - - -
Pediatrics 6,915 2,091 287 530 1,700 1,910 204 129 47 17
Pathology Group 3,956 2,416 79 77 1,022 221 65 18 57 1 Chemical Pathology 251 159 4 3 63 9 11 - 2 -
Clinical Cytogenetics and Molecular Genetics
24 16 1 - 7 - - - - -
Hematology 1,308 663 47 60 321 133 21 14 48 1 Histopathology 1,643 1,087 16 12 441 64 17 3 3 -
Immunology 103 62 1 1 34 - - 1 4 - Medical Microbiology & Virology
627 429 10 1 156 15 16 - - -
PHM & CHS Group 3,283 885 143 183 179 40 71 - 49 1,733
Dental public health 1,529 69 3 1 14 1 - - 3 1,438
Public Health Medicine 1,754 816 140 182 165 39 71 - 46 295
170
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006 Table No 3. Medical Staff by specialty and Grade (Cont…)
SPECIALTY TOTAL
CONSULTANT (INCLUDING DIRECTOR OF PUBLIC HEALTH)
ASSOCIATE SPECIALIST
STAFF GRADE
REGISTRAR GROUP
SENIOR HOUSE
OFFICER
FOUNDATION YEAR 2
HOUSE OFFICER &
FOUNDATION PROGRAM
YEAR 1
HOSPITAL PRACTITIONER/
CLINICAL ASSISTANT
OTHER STAFF
Psychiatry Group 9,629 3,805 473 1,236 1,022 2,554 88 50 377 24 Child and Adolescent Psychiatry
1,060 615 33 79 164 151 - 4 11 3
Forensic Psychiatry 519 239 26 66 82 101 - - 5 -
General Psychiatry 6,090 2,107 316 823 585 1,921 74 39 208 17 Learning Disabilities 531 216 18 72 46 84 - 3 89 3
Old age Psychiatry 1,271 521 77 192 124 284 12 1 59 1 Psychotherapy 158 107 3 4 21 13 2 3 5 -
Radiology Group 3,204 2,105 27 31 1,004 8 10 2 17 - Clinical Radiology 3,129 2,061 25 30 981 7 8 2 15 - Nuclear Medicine 75 44 2 1 23 1 2 - 2 -
Surgical Group 19,425 6,129 726 1,114 4,331 3,897 754 2,032 438 4 Cardiothoracic Surgery 717 240 4 15 251 166 26 11 4 -
General Surgery 6,591 1,756 151 272 1,302 1,100 268 1,598 144 - Neurosurgery 553 187 3 5 208 121 20 9 - -
Ophthalmology 2,293 816 194 287 434 391 36 7 124 4 Otolaryngology 1,614 552 89 127 310 374 72 24 66 - Pediatric Surgery 304 104 1 5 95 81 10 8 - - Plastic Surgery 780 254 23 20 244 210 16 7 6 - Trauma and Orthopedic Surgery
5,163 1,710 201 295 1,193 1,210 264 220 70 -
Urology 1,410 510 60 88 294 244 42 148 24 -
Source: IC (2007) NHS Hospital and Community Health Services: Medical and Dental Workforce Census England - 30 September 2006 - Detailed Results [internet], IC. Available from: <http://www.ic.nhs.uk/webfiles/publications/nhsstaff2006/med/Medical%20and%20Dental%20Detailed%20Results%202006.pdf> [Accessed September 2007]
171
NORTHERN IRELAND
172
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN NORTHERN IRELAND 2007 Table No 1. Total Physicians by Specialty and Gender SPECIALTY TOTAL MALE % FEMALE %
TOTAL PHYSICIANS 4,798 2,814 59 1,984 41 Anesthesiology 364 246 68 118 32 Cardiothoracic Surgery 27 24 89 3 11 Cardiovascular Diseases 104 72 69 32 31 Dermatology 42 13 31 29 69 Emergency Medicine 191 126 66 65 34 General Physicians / General Practitioners / Family Doctors 1,110 703 63 407 37 General Surgery / Vascular Surgery 317 231 73 86 27 Internal Medicine 812 455 56 357 44
Medical Oncology 6 5 78 1 22 Neurology 18 13 72 5 28 Neurosurgery 18 15 83 3 17 Obstetrics and Gynecology 233 102 44 131 56 Ophthalmology 70 37 53 33 47 Orthopedic Surgery and Traumatology 118 98 83 20 17 Otolaryngology 74 53 72 21 28 Pathology 84 52 62 32 38
Pediatric & Pediatric Surgery 228 102 45 126 55 Physical Medicine, Rehabilitation and Rheumatology 37 14 38 23 62 Plastic Surgery 25 19 76 6 24 Psychiatry 323 145 45 178 55 Public Health / Community Medicine / Occupational Medicine 157 50 32 107 68 Radiology 188 127 68 61 32 Urology / Renal Failure Surgery 30 23 77 7 23 Other Specialties 49 30 61 19 39
Dental Group 173 59 34 114 66
Source: Workforce Statistics; Health, Social Service and Public Safety Department, Statistics and Research, Medical Staff, 2007 [Accessed October 2007].
173
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN NORTHERN IRELAND 2007 Table No 2. Total Physicians by Specialty and Age
SPECIALTY TOTAL UNDER 35 35-44 45-54 55-64 65 AND OVER
TOTAL PHYSICIANS 4,653 1,710 1,417 1,070 428 28 Anesthesiology 364 128 116 81 36 2 Cardiovascular Diseases 104 51 27 13 14 0 Dermatology 42 11 15 13 4 0 Emergency Medicine 191 103 61 21 6 0 General Physicians / General Practitioners / Family Doctors 1,110 137 428 401 132 11 General Surgery / Vascular Surgery 317 183 69 42 23 1 Internal Medicine 812 507 146 111 45 3 Medical Oncology 6 2 2 3 0 0 Neurology 18 7 8 3 0 0 Neurosurgery 18 6 8 2 2 0 Obstetrics and Gynecology 233 102 70 32 25 4 Ophthalmology 70 23 28 10 9 0 Orthopedic Surgery and Traumatology 118 59 35 15 9 0 Otolaryngology 74 30 21 15 8 0 Pathology 84 28 26 22 7 1 Pediatric Surgery 228 119 66 28 15 0 Physical Medicine, Rehabilitation and Rheumatology 37 28 3 5 1 0 Plastic Surgery 25 8 11 3 3 0 Psychiatry 323 141 90 73 18 1 Public Health / Community Medicine / Occupational Medicine 157 13 49 67 28 0 Radiology 188 89 49 30 20 0 Thoracic Surgery 27 10 9 5 2 0 Urology / Renal Failure Surgery 30 12 10 5 2 1 Other Specialties 49 5 19 13 11 1
Assumptions: It was assumed that distribution of physicians in each specialty by age group would remain similar in 2007 to that of in 2002 Source: Workforce Statistics; Health, Social Service and Public Safety Department, Statistics and Research, Medical Staff, 2007, [Accessed October 2007].
174
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN NORTHERN IRELAND 2007 Table No 3. Medical Staff by Specialty and Grade
SPECIALTY TOTAL CONSULTANT
STAFF GRADE
ASSOCIATE SPECIALIST
SPECIALIST REGISTRAR
SENIOR HOUSE
OFFICER
MEDICAL OFFICER
HOSPITAL PRACTITI
ONER
GENERAL/ MEDICAL PRACTITI
ONER
OTHER STAFF
TOTAL PHYSICIANS 3,515 1,143 187 56 614 1,237 78 73 102 25
Anesthesiology 364 206 16 4 63 74 0 0 1 0 Cardiovascular Diseases 104 32 6 3 25 32 0 4 0 1
Dermatology 42 13 0 3 7 2 0 6 11 1 Emergency Medicine 191 31 34 6 12 84 0 12 11 0
General Physicians / General Practitioners / Family Doctors
0 0 0 0 0 0 0 0 0 0
General Surgery / Vascular Surgery 317 85 10 1 51 164 1 2 1 1
Internal Medicine 812 184 37 10 97 411 6 34 30 4 Medical Oncology 6 5 0 2 0 0 0 0 0 0 Neurology 18 8 0 0 7 3 0 0 0 0 Neurosurgery 18 8 0 0 8 2 0 0 0 0 Obstetrics and Gynecology 233 73 2 4 59 92 2 1 0 0
Ophthalmology 70 25 6 5 15 11 4 1 0 1 Orthopedic Surgery and Traumatology 118 43 7 1 28 37 0 1 0 0
Otolaryngology 74 28 5 0 14 21 0 1 5 0 Pathology 84 44 2 1 24 8 0 0 5 1
175
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN NORTHERN IRELAND 2007 Table No 3. Medical Staff by Specialty and Grade (Cont…)
SPECIALTY TOTAL CONSULTANT
STAFF GRADE
ASSOCIATE SPECIALIST
SPECIALIST REGISTRAR
SENIOR HOUSE
OFFICER
MEDICAL OFFICER
HOSPITAL PRACTITI
ONER
GENERAL/ MEDICAL PRACTITI
ONER
OTHER STAFF
Pediatric & Pediatric Surgery 228 60 25 1 42 92 2 1 5 0
Physical Medicine, Rehabilitation and Rheumatology
37 9 0 0 15 13 0 0 0 0
Plastic Surgery 25 10 0 0 10 6 0 0 0 0 Psychiatry 323 125 18 9 38 123 2 4 4 1 Public Health / Community Medicine / Occupational Medicine
157 33 18 6 9 2 55 4 23 8
Radiology 188 69 0 0 69 49 0 0 0 0 Thoracic Surgery 27 15 1 0 8 2 0 0 0 0 Urology / Renal Failure Surgery 30 12 0 0 11 7 0 0 0 0
Other Specialties 49 25 0 1 3 0 5 1 8 6
Assumptions: It was assumed that distribution of physicians in each specialty by grade would remain similar in 2007 to that of in 2002 Source: Workforce Statistics; Health, Social Service and Public Safety Department, Statistics and Research, Medical Staff, 2007. [Accessed October 2007]
176
SCOTLAND
177
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006 Table No 1. Total Physicians by Specialty and Gender SPECIALTY TOTAL MALE % FEMALE %
TOTAL PHYSICIANS 11,203 6,292 56 4,911 44 All Medical Specialties 10,500 5,972 57 4,528 43
Hospital Medical Specialties 9,952 5,780 58 4,172 42 Anesthesiology 1,065 672 63 393 37 Emergency Medicine 494 288 58 206 42
Clinical Laboratory Specialties 555 292 53 263 47 Chemical Pathology 40 30 75 10 25 Clinical Genetics 24 9 38 15 63 Hematology 182 90 49 92 51
Histopathology 212 111 52 101 48 Immunology 6 4 67 2 33 Medical Microbiology & Virology 91 48 53 43 47
Medical Specialties 3,570 1,918 54 1,652 46 Audiological Medicine 2 1 50 1 50 Dermatology 158 63 40 95 60
General Medicine (group) 1,871 1,071 57 800 43 Cardiology 185 134 72 51 28 Clinical Neuro-Physiology 5 3 60 2 40 Clinical Oncology 115 63 55 52 45 Clinical Pharmacology & Therapeutics 27 21 78 6 22 Endocrinology & Diabetes 136 85 63 51 38 Gastroenterology 137 105 77 32 23 General (acute) Medicine 970 462 48 508 52 Genito - Urinary Medicine 51 21 41 30 59 Geriatrics 534 297 56 237 44 Homoeopathy 17 9 53 8 47
Infectious Diseases 53 30 57 23 43 Intensive Care Medicine 17 11 65 6 35 Medical Oncology 62 21 34 41 66
178
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006 Table No 1. Total Physicians by Specialty and Gender (Cont…) SPECIALTY TOTAL MALE % FEMALE %
Medical Ophthalmology 3 2 67 1 33
Neurology 87 57 66 30 34 Obstetrics & Gynecology 568 226 40 342 60 Occupational Medicine 54 29 54 25 46 Pediatric Cardiology 12 8 67 4 33 Pediatrics 536 243 45 293 55 Palliative Medicine 69 27 39 42 61 Rehabilitation Medicine 52 33 63 19 37 Renal Medicine 120 73 61 47 39
Respiratory Medicine 150 110 73 40 27 Rheumatology 83 44 53 39 47
Psychiatric Specialties 1,152 568 49 584 51 Child & Adolescent Psychiatry 105 26 25 79 75 Forensic Psychiatry 49 26 53 23 47 General Psychiatry 744 393 53 351 47 Old age Psychiatry 150 79 53 71 47 Psychiatry of Learning Disability 87 39 45 48 55 Psychotherapy 21 7 33 14 67
Radiology 344 231 67 113 33 Clinical Radiology 337 225 67 112 33 Nuclear Medicine 7 6 86 1 14
Surgical Specialties 2,177 1,573 72 604 28 Cardiothoracic Surgery 79 67 85 12 15 ENT Surgery 165 121 73 44 27 General Surgery 874 566 65 308 35 Neurosurgery 58 47 81 11 19
Ophthalmology 232 154 66 78 34 Oral & Maxillofacial Surgery 32 31 97 1 3 Pediatric Surgery 62 38 61 24 39
179
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006 Table No 1. Total Physicians by Specialty and Gender (Cont…) SPECIALTY TOTAL MALE % FEMALE %
Plastic Surgery 84 58 69 26 31
Trauma & Orthopedic surgery 471 390 83 81 17 Urology 121 102 84 19 16
Public Health Medicine 171 87 51 84 49 Community Medical Specialties 399 112 28 287 72 Breast Screening Service 20 3 15 17 85 Community Child Health 135 15 11 120 89 Community Psychiatry 8 6 75 2 25 Family Planning 87 10 11 77 89
General Practice 145 78 54 67 46 Women’s Health Service 5 - 0 5 100
All Dental Specialties 703 320 46 383 54 Hospital Dental Specialties 308 181 59 127 41 Dental & Maxillofacial Radiology 6 2 33 4 67 Fixed & Removable Prosthodontics 1 - 0 1 100 Oral Medicine 14 9 64 5 36 Oral Microbiology 4 3 75 1 25 Oral Pathology 1 1 100 - 0 Oral Surgery 103 60 58 43 42 Orthodontics 70 39 56 31 44 Pediatric Dentistry 26 6 23 20 77 Restorative Dentistry 84 61 73 23 27 Surgical Dentistry - - -
Community Dental Specialties 401 141 35 260 65 Community Dentistry 378 127 34 251 66 Dental Public Health 23 14 61 9 39
General Practitioners 4,637 2,439 53 2198 47
Note: The statistics includes employees working in more than one Board / Region / Specialty or Grade and is presented under each group but counted once in the total. Source: ISD Scotland (2007) NHS Scotland Workforce Statistics - Table B5: HCHS staff by gender, contract type, specialty, NHS Board and Region [internet], ISD Scotland. Available from: <http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=WFB05_HB_REG.xls&pContentDispositionType=inline> [Accessed September 2007].
180
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006 Table No 2. Total Physicians by Specialty and Age SPECIALTY TOTAL UNDER 35 35-44 45-54 55-59 60 AND OVER
TOTAL PHYSICIANS 11,203 4,811 2,920 2,286 785 401 All Medical Specialties 10,500 4,591 2,718 2,101 728 362
Hospital Medical Specialties 9,952 4,485 2,570 1,901 667 329 Anesthesiology 1,065 350 354 246 85 30 Emergency Medicine 494 330 91 55 13 5
Clinical Laboratory Specialties 555 138 152 169 65 31 Chemical Pathology 40 5 16 11 5 3 Clinical Genetics 24 1 7 12 4 0 Hematology 182 59 46 47 21 9
Histopathology 212 56 52 64 25 15 Immunology 6 0 1 3 1 1 Medical Microbiology & Virology 91 17 30 32 9 3
Medical Specialties 3,570 1,824 794 604 237 111 Audiological medicine 2 0 0 2 0 0 Dermatology 158 47 47 48 13 3
General medicine (group) 1,871 1,095 358 263 108 47 Cardiology 185 69 50 40 19 7 Clinical Neuro-Physiology 5 0 2 1 2 0 Clinical Oncology 115 45 38 17 8 7 Clinical Pharmacology & Therapeutics 27 8 9 6 2 2 Endocrinology & Diabetes 136 29 49 40 12 6 Gastroenterology 137 39 48 30 13 7 General (acute) Medicine 970 803 65 69 24 9 Genito - Urinary Medicine 51 13 15 11 7 5 Geriatrics 534 241 112 115 47 19 Homoeopathy 17 1 0 11 3 2
Infectious Diseases 53 24 12 10 7 0 Intensive Care Medicine 17 14 3 0 0 0 Medical Oncology 62 27 20 11 1 3
181
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006 Table No 2. Total Physicians by Specialty and Age (Cont…) SPECIALTY TOTAL UNDER 35 35-44 45-54 55-59 60 AND OVER
Medical Ophthalmology 3 2 1 0 0 0
Neurology 87 26 36 15 8 2 Obstetrics & Gynecology 568 257 149 102 36 24 Occupational Medicine 54 8 13 23 7 3 Palliative Medicine 69 20 18 21 10 0 Pediatric Cardiology 12 5 4 1 1 1 Pediatrics 536 276 134 80 25 21 Rehabilitation Medicine 52 17 11 16 6 2 Renal Medicine 120 36 46 24 9 5
Respiratory Medicine 150 53 48 26 16 7 Rheumatology 83 29 27 17 7 3
Psychiatric Specialties 1,152 416 356 286 61 33 Child & Adolescent Psychiatry 105 19 40 39 6 1 Forensic Psychiatry 49 12 22 11 3 1 General Psychiatry 744 327 213 156 30 18 Old age Psychiatry 150 33 59 38 10 10 Psychiatry of Learning Disability 87 25 15 33 11 3 Psychotherapy 21 0 9 9 3 0
Radiology 344 85 126 91 28 14 Clinical Radiology 337 85 122 89 27 14 Nuclear Medicine 7 0 4 2 1 0
Surgical Specialties 2,177 1,077 536 339 143 82 Cardiothoracic Surgery 79 34 20 18 5 2 ENT Surgery 165 66 41 35 12 11 General Surgery 874 528 153 117 49 27 Neurosurgery 58 30 16 6 5 1
Ophthalmology 232 68 84 45 21 14 Oral & Maxillofacial Surgery 32 0 15 10 5 2 Pediatric Surgery 62 39 11 6 4 2
182
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006 Table No 2. Total Physicians by Specialty and Age (Cont…) SPECIALTY TOTAL UNDER 35 35-44 45-54 55-59 60 AND OVER
Plastic Surgery 84 37 33 7 7 0
Trauma & Orthopedic Surgery 471 234 119 71 26 21 Urology 121 41 45 24 9 2
Public Health Medicine 171 9 55 70 22 15 Community Medical Specialties 399 97 100 140 41 21 Breast Screening Service 20 2 5 11 1 1 Community Child Health 135 7 36 61 22 9 Community Psychiatry 8 0 4 3 0 1 Family Planning 87 17 26 26 11 7
General Practice 145 70 28 38 6 3 Women’s Health Service 5 1 1 2 1 0
All Dental Specialties 703 220 202 185 57 39 Hospital Dental Specialties 308 104 80 69 30 25 Dental & Maxillofacial Radiology 6 3 1 2 0 0 Fixed & Removable Prosthodontics 1 0 1 0 0 0 Oral Medicine 14 2 3 6 3 0 Oral Microbiology 4 2 1 1 0 0 Oral Pathology 1 0 0 0 0 1 Oral Surgery 103 53 23 13 7 7 Orthodontics 70 14 24 19 9 4 Pediatric Dentistry 26 12 6 7 0 1 Restorative Dentistry 84 18 21 21 12 12 Surgical Dentistry 0 0 0 0 0 0
Community Dental Specialties 401 117 126 116 27 15 Community Dentistry 378 115 123 107 23 10 Dental Public Health 23 2 3 9 4 5
General Practitioners 4,636 813 1,581 1,556 517 169
Note: The statistics includes employees working in more than one Board / Region / Specialty or Grade and is presented under each group but counted once in the total. Source: ISD Scotland (2007) NHS Scotland Workforce Statistics - Table B6: HCHS staff by specialty by age group, NHS Board and Region [internet], ISD Scotland. Available from: <http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=WFB06_HB_REG.xls&pContentDispositionType=inline> [Accessed September 2007].
183
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006 Table No 3. Medical Staff by Specialty and Grade
SPECIALTY TOTAL
CONSULTANT (INCLUDING DIRECTORS OF PUBLIC HEALTH)
STAFF GRADE
ASSOCIATE SPECIALIST
REGISTRAR GROUP
SENIOR HOUSE
OFFICERS / FOUNDATION
YEAR 2
HOUSE OFFICERS /
FOUNDATION YEAR 1
SENIOR CLINICAL MEDICAL OFFICER
CLINICAL MEDICAL OFFICER
GMP / GDP
GRADES1 OTHER
TOTAL PHYSICIANS 11,203 3,847 535 244 1,646 2,993 793 11 7 658 505
All Medical Specialties 10,500 3,751 513 231 1,611 2,930 793 11 7 586 97
Hospital Medical Specialties
9,952 3,576 398 194 1,580 2,865 790 2 1 527 33
Anesthesiology 1,065 560 45 22 191 225 11 - - 12 - Emergency Medicine 494 76 19 7 52 288 6 - - 34 12
Clinical Laboratory Specialties
555 328 13 14 142 36 2 - - 20 1
Chemical Pathology 40 26 - - 12 1 - - - 1 -
Clinical Genetics 24 15 1 1 6 - - - - - 1
Hematology 182 84 10 7 42 23 2 - - 15 - Histopathology 212 140 1 5 56 7 - - - 3 - Immunology 6 6 - - - - - - - - - Medical Microbiology & Virology
91 57 1 1 26 5 - - - 1 -
Medical Specialties 3,570 981 130 70 511 1,129 424 1 1 314 13
Audiological medicine 2 1 - 1 - - - - - - -
Dermatology 158 55 6 5 26 25 - - - 40 1 General medicine (group)
1,871 464 47 33 242 572 388 - 1 114 11
Cardiology 185 78 9 1 47 32 9 - - 8 1
184
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006 Table No 3. Medical Staff by Specialty and Grade (Cont…)
SPECIALTY TOTAL
CONSULTANT (INCLUDING DIRECTORS OF PUBLIC HEALTH)
STAFF GRADE
ASSOCIATE SPECIALIST
REGISTRAR GROUP
SENIOR HOUSE
OFFICERS / FOUNDATION
YEAR 2
HOUSE OFFICERS /
FOUNDATION YEAR 1
SENIOR CLINICAL MEDICAL OFFICER
CLINICAL MEDICAL OFFICER
GMP / GDP
GRADES1 OTHER
Clinical Neuro-Physiology 5 5 - - - - - - - - -
Clinical Oncology 115 55 5 - 36 18 - - - 1 -
Clinical Pharmacology & Therapeutics
27 13 1 - 11 1 - - - 1 -
Endocrinology & Diabetes 136 70 2 - 27 11 - - 1 25 -
Gastroenterology 137 84 4 1 32 13 2 - - - 1 General (acute) Medicine 970 29 19 18 20 435 367 - - 75 8
Genito - Urinary Medicine 51 15 2 3 5 7 - - - 19 -
Geriatrics 534 128 22 11 51 188 25 - - 109 - Homoeopathy 17 2 - 6 1 1 - - - 7 - Infectious Diseases 53 19 4 1 11 16 2 - - - -
Intensive Care Medicine 17 1 - - 3 13 - - - - -
Medical Oncology 62 20 5 1 24 10 2 - - - -
Medical Ophthalmology 3 1 - - 1 1 - - - - -
Neurology 87 48 1 1 20 13 3 - - 2 - Obstetrics & Gynecology 568 171 22 13 86 240 4 1 - 28 4
Occupational Medicine 54 22 - 1 13 1 - - - 16 1
Pediatric Cardiology 12 5 - - 4 3 - - - - -
Pediatrics 536 141 30 8 84 256 5 1 - 11 -
185
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006 Table No 3. Medical Staff by Specialty and Grade (Cont…)
SPECIALTY TOTAL
CONSULTANT (INCLUDING DIRECTORS OF PUBLIC HEALTH)
STAFF GRADE
ASSOCIATE SPECIALIST
REGISTRAR GROUP
SENIOR HOUSE
OFFICERS / FOUNDATION
YEAR 2
HOUSE OFFICERS /
FOUNDATION YEAR 1
SENIOR CLINICAL MEDICAL OFFICER
CLINICAL MEDICAL OFFICER
GMP / GDP
GRADES1 OTHER
Palliative Medicine 69 29 5 - 15 11 1 - - 7 1
Rehabilitation Medicine 52 18 7 2 4 14 - - - 7 -
Renal Medicine 120 51 4 6 31 25 2 - - 1 - Respiratory Medicine 150 73 2 2 39 25 6 - - 2 1
Rheumatology 83 44 2 4 20 11 - - - 2 - Psychiatric Specialties 1,152 488 109 23 107 333 2 - - 90 1
Child & Adolescent Psychiatry
105 68 10 2 16 8 - - - 1 -
Forensic Psychiatry 49 35 - - 10 4 - - - - -
General Psychiatry 744 264 75 13 56 289 2 - - 45 -
Old age Psychiatry 150 75 19 4 16 16 - - - 20 -
Psychiatry of Learning Disability
87 29 6 3 8 16 - - - 24 1
Psychotherapy 21 17 1 1 1 - - - - 1 -
Radiology 344 234 - 3 106 1 - - - - - Clinical Radiology 337 228 - 3 105 1 - - - - -
Nuclear Medicine 7 6 - - 1 - - - - - -
186
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006 Table No 3. Medical Staff by Specialty and Grade (Cont…)
SPECIALTY TOTAL
CONSULTANT (INCLUDING DIRECTORS OF PUBLIC HEALTH)
STAFF GRADE
ASSOCIATE SPECIALIST
REGISTRAR GROUP
SENIOR HOUSE
OFFICERS / FOUNDATION
YEAR 2
HOUSE OFFICERS /
FOUNDATION YEAR 1
SENIOR CLINICAL MEDICAL OFFICER
CLINICAL MEDICAL OFFICER
GMP / GDP
GRADES1 OTHER
Surgical Specialties 2,177 719 60 41 372 612 341 - - 31 1
Cardiothoracic Surgery 79 27 1 2 17 28 3 - - - 1
ENT Surgery 165 66 8 4 34 51 1 - - 1 - General Surgery 874 234 19 8 102 218 280 - - 13 -
Neurosurgery 58 21 - - 11 24 2 - - - - Ophthalmology 232 89 15 15 52 47 5 - - 9 - Oral & Maxillofacial Surgery
32 24 - - 8 - - - - - -
Pediatric Surgery 62 15 1 - 10 17 19 - - - -
Plastic Surgery 84 26 - 1 20 33 2 - - 2 - Trauma & Orthopedic surgery
471 163 12 10 90 168 23 - - 5 -
Urology 121 54 5 1 28 26 6 - - 1 - Public Health Medicine 171 117 3 1 29 - - 1 3 4 14
Community Medical Specialties
399 60 113 37 2 65 3 8 3 61 50
Breast Screening Service
20 8 4 - - - 2 - - 5 1
Community Child Health 135 37 62 22 - 4 - 4 - 6 -
Community Psychiatry 8 2 1 - - - - - - 5 -
Family Planning 87 11 45 15 2 - - 4 1 11 -
187
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006 Table No 3. Medical Staff by Specialty and Grade (Cont…)
SPECIALTY TOTAL
CONSULTANT (INCLUDING DIRECTORS OF PUBLIC HEALTH)
STAFF GRADE
ASSOCIATE SPECIALIST
REGISTRAR GROUP
SENIOR HOUSE
OFFICERS / FOUNDATION
YEAR 2
HOUSE OFFICERS /
FOUNDATION YEAR 1
SENIOR CLINICAL MEDICAL OFFICER
CLINICAL MEDICAL OFFICER
GMP / GDP
GRADES1 OTHER
General Practice 145 - 1 - - 61 1 - - 33 49
Women’s Health Service 5 2 - - - - - - 2 1 -
All Dental Specialties 703 96 22 13 35 63 - - - 72 408
Hospital Dental Specialties
308 86 22 13 33 63 - - - 71 20
Dental & Maxillofacial Radiology
6 2 - - 1 3 - - - - -
Fixed & Removable Prosthodontics
1 - - - 1 - - - - - -
Oral Medicine 14 7 2 - 1 - - - - 3 1 Oral Microbiology 4 2 - - - 2 - - - - -
Oral Pathology 1 1 - - - - - - - - - Oral Surgery 103 7 14 9 3 41 - - - 17 12 Orthodontics 70 27 3 4 17 2 - - - 17 - Pediatric Dentistry 26 10 2 - 7 5 - - - 1 1
Restorative Dentistry 84 30 2 - 3 10 - - - 33 6
Surgical Dentistry - - - - - - - - - - -
Community Dental Specialties
401 10 - - 2 - - - - 1 388
Community Dentistry 378 - - - - - - - - - 378
Dental Public Health 23 10 - - 2 - - - - 1 10
188
Source: ISD Scotland (2007) NHS Scotland Workforce Statistics - Table B9: HCHS medical and dental staff by specialty, grade, NHS Board and Region [internet], ISD Scotland. Available from: <http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=WFB09_HB_REG.xls> [Accessed September 2007].
189
WALES
190
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005 Table No 1. Total Physicians by Specialty and Gender SPECIALTY TOTAL MALE % FEMALE %
TOTAL PHYSICIANS 7,136 4,699 66 2,437 34 All Medical Specialties 5,045 3,357 67 1,688 33
All Dental Specialties 209 140 67 69 33 Medical Specialties Accident & Emergency 253 176 70 77 30 Anesthesiology 625 440 70 185 30 Audiological Medicine 3 1 33 2 67 Blood Transfusion 4 2 50 2 50 Cardiology 76 63 83 13 17
Cardio-thoracic Surgery 32 29 91 3 9 Chemical Pathology 21 13 62 8 38 Child & Adolescent Psychiatry 60 30 50 30 50 Clinical Genetics 21 6 29 15 71 Clinical Immunology and Allergy 1 1 100 - 0 Clinical Neuro Physiology 4 4 100 - 0 Clinical Oncology 69 36 52 33 48 Clinical Pharmacology and Therapeutics 4 4 100 - 0 Clinical Radiology 157 103 66 54 34 Dermatology 72 46 64 26 36 Endocrinology & Diabetes Mellitus 40 30 75 10 25 Forensic Psychiatry 18 11 61 7 39 Gastroenterology 45 32 71 13 29 General Medicine 494 325 66 169 34 General Psychiatry 284 171 60 113 40 General Surgery 398 301 76 97 24 Genito-urinary Medicine 46 16 35 30 65
Geriatric Medicine 250 195 78 55 22 Hematology 78 50 64 28 36 Histopathology 71 52 73 19 27
191
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005 Table No 1. Total Physicians by Specialty and Gender (Cont…) SPECIALTY TOTAL MALE % FEMALE %
Immunology 3 2 67 1 33
Infectious Diseases 2 2 100 - 0 Intensive Care Medicine 16 12 75 4 25 Medical Microbiology and Virology 45 25 56 20 44 Medical Oncology 13 6 46 7 54 Neurology 38 23 61 15 39 Neurosurgery 20 19 95 1 5 Nuclear Medicine 1 1 100 - 0 Obstetrics & Gynecology 308 134 44 174 56 Occupational Medicine 15 12 80 3 20
Old age Psychiatry 83 46 55 37 45 Ophthalmology 140 103 74 37 26 Otolaryngology 117 97 83 20 17 Pediatric Cardiology 5 5 100 - 0 Pediatric Neurology 3 1 33 2 67 Pediatric Surgery 10 9 90 1 10 Pediatrics 432 207 48 225 52 Palliative Medicine 45 7 16 38 84 Plastic Surgery 36 30 83 6 17
Psychiatry of Learning Disability 40 26 65 14 35 Psychotherapy 5 3 60 2 40 Rehabilitation Medicine 15 8 53 7 47 Renal Medicine 44 36 82 8 18 Respiratory Medicine 74 58 78 16 22 Rheumatology 49 31 63 18 37 Traumatic & Orthopedic Surgery 269 244 91 25 9 Urology 79 68 86 11 14
Other 12 5 42 7 58
192
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005 Table No 1. Total Physicians by Specialty and Gender (Cont…) SPECIALTY TOTAL MALE % FEMALE %
Dental Specialties 0
Dental Medical Specialties 5 2 40 3 60 Oral and Maxillofacial Surgery 92 65 71 27 29 Oral Surgery 5 5 100 - 0 Orthodontics 40 26 65 14 35 Pediatric Dentistry 8 3 38 5 63 Restorative Dentistry 59 39 66 20 34
GP's 1,882 1,202 64 680 36
Source:
1) Health Statistics and Analysis Unit, Wales Assembly Government, 2005 [Accessed October 2007] 2) Stats Wales (2007) GP Headcount (gender, age group) [internet], stats Wales. Available from: <http://www.statswales.wales.gov.uk/TableViewer/tableView.aspx?ReportId=1617> [Accessed October
2007]
193
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005 Table No 2. Total Physicians by Specialty and Age SPECIALTY TOTAL UNDER 35 35-44 45-54 55-64 65 AND OVER
TOTAL PHYSICIANS 5,254 1,927 1,529 1,134 614 50 All Medical Specialties 5,045 1,857 1,481 1,080 580 47
All Dental Specialties 209 70 48 54 34 3
Medical Specialties Accident & Emergency 253 125 64 43 20 1 Anesthesiology 625 193 227 128 72 5 Audiological Medicine 3 0 2 0 1 0 Blood Transfusion 4 0 0 2 1 1 Cardiology 76 32 25 17 2 0
Cardio-thoracic Surgery 32 10 13 7 2 0 Chemical Pathology 21 6 3 10 2 0 Child & Adolescent Psychiatry 60 13 18 23 4 2 Clinical Genetics 21 1 8 10 2 0 Clinical Immunology and Allergy 1 1 0 0 0 0 Clinical Neuro Physiology 4 1 0 2 0 1 Clinical Oncology 69 24 18 15 12 0 Clinical Pharmacology and Therapeutics 4 0 1 1 2 0 Clinical Radiology 157 32 43 60 22 0 Dermatology 72 13 30 16 12 1 Endocrinology & Diabetes Mellitus 40 19 15 3 3 0 Forensic Psychiatry 18 6 7 5 0 0 Gastroenterology 45 21 18 5 1 0 General Medicine 494 304 69 67 47 7 General Psychiatry 284 88 90 67 34 5 General Surgery 398 193 94 66 42 3 Genito-urinary Medicine 46 5 15 18 6 2
Geriatric Medicine 250 82 69 58 36 5 Hematology 78 18 22 22 16 0 Histopathology 71 17 9 34 11 0
194
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005 Table No 2. Total Physicians by Specialty and Age (Cont…) SPECIALTY TOTAL UNDER 35 35-44 45-54 55-64 65 AND OVER
Immunology 3 1 1 1 0 0
Infectious Diseases 2 2 0 0 0 0 Intensive Care Medicine 16 4 11 1 0 0 Medical Microbiology and Virology 45 6 15 15 8 1 Medical Oncology 13 4 5 4 0 0 Neurology 38 17 12 6 2 1 Neurosurgery 20 6 5 6 3 0 Nuclear Medicine 1 0 1 0 0 0 Obstetrics & Gynecology 308 99 102 60 43 4
Occupational Medicine 15 2 3 7 3 0 Old age Psychiatry 83 18 25 26 13 1 Ophthalmology 140 34 45 38 21 2 Otolaryngology 117 43 30 27 17 0 Pediatric Cardiology 5 1 2 1 1 0 Pediatric Neurology 3 0 2 1 0 0 Pediatric Surgery 10 3 2 4 1 0 Pediatrics 432 168 134 85 43 2 Palliative Medicine 45 18 12 9 6 0 Plastic Surgery 36 16 14 4 2 0 Psychiatry of Learning Disability 40 9 15 14 2 0 Psychotherapy 5 3 0 1 1 0 Rehabilitation Medicine 15 3 6 3 3 0 Renal Medicine 44 20 13 8 2 1 Respiratory Medicine 74 31 29 7 7 0 Rheumatology 49 12 18 8 10 1 Traumatic & Orthopedic Surgery 269 101 91 46 31 0
Urology 79 30 26 15 8 0 Other 12 2 2 4 3 1
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PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005 Table No 2. Total Physicians by Specialty and Age (Cont…) SPECIALTY TOTAL UNDER 35 35-44 45-54 55-64 65 AND OVER
Dental Specialties -
Dental Medical Specialties 5 0 3 2 0 0 Oral and Maxillofacial Surgery 92 36 20 19 15 2 Oral Surgery 5 1 1 2 1 0 Orthodontics 40 12 9 9 9 1 Pediatric Dentistry 8 3 0 4 1 0 Restorative Dentistry 59 18 15 18 8 0
GP's 1,882 193 597 719 338 35
Source: Health Statistics and Analysis Unit, Wales Assembly Government, 2005 [Accessed October 2007]
196
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005 Table No 3. Medical Staff by Specialty and Grade
SPECIALTY TOTAL CONSULTANT ASSOCIATE SPECIALIST
STAFF GRADE
SPECIALIST REGISTRAR
SENIOR HOUSE
OFFICER
HOUSE OFFICER
HOSPITAL PRACTITIONER
CLINICAL ASSISTANT
OTHER STAFF
TOTAL PHYSICIANS 5,254 1,801 174 483 850 1,269 257 56 307 57
All Medical Specialties 5,045 1,746 158 461 826 1,232 257 55 253 57
All Dental Specialties 209 55 16 22 24 37 0 1 54 0
Medical Specialties 0 0 0 Accident & Emergency 253 34 10 44 23 98 9 2 28 5
Anesthesiology 625 275 18 43 126 146 7 4 6 0 Audiological Medicine 3 1 0 0 2 0 0 0 0 0 Blood Transfusion 4 1 2 0 0 0 0 0 1 0 Cardiology 76 26 1 2 29 10 2 4 2 0 Cardio-thoracic Surgery 32 12 0 2 8 8 0 0 0 2
Chemical Pathology 21 12 0 0 7 1 0 0 1 0 Child & Adolescent Psychiatry 60 30 3 8 7 11 0 0 1 0
Clinical Genetics 21 11 4 2 4 0 0 0 0 0 Clinical Immunology and Allergy 1 0 0 0 1 0 0 0 0 0
Clinical Neuro Physiology 4 3 0 0 1 0 0 0 0 0
Clinical Oncology 69 31 0 4 22 9 0 1 2 0 Clinical Pharmacology and Therapeutics 4 3 0 0 1 0 0 0 0 0
Clinical Radiology 157 115 0 1 36 4 0 0 1 0 Dermatology 72 21 2 3 12 5 0 7 22 0 Endocrinology & Diabetes Mellitus 40 9 0 0 21 5 0 0 4 1
197
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005 Table No 3. Medical Staff by Specialty and Grade (Cont…)
SPECIALTY TOTAL CONSULTANT ASSOCIATE SPECIALIST
STAFF GRADE
SPECIALIST REGISTRAR
SENIOR HOUSE
OFFICER
HOUSE OFFICER
HOSPITAL PRACTITIONER
CLINICAL ASSISTANT
OTHER STAFF
Forensic Psychiatry 18 7 1 2 1 7 0 0 0 0 Gastroenterology 45 12 1 0 28 3 1 0 0 0 General Medicine 494 107 9 40 1 204 97 3 23 10 General Psychiatry 284 97 11 46 20 85 0 5 17 3 General Surgery 398 114 9 31 62 76 94 1 4 7 Genito-urinary Medicine 46 12 0 8 6 0 0 0 20 0
Geriatric Medicine 250 55 3 21 29 74 8 6 53 1 Hematology 78 41 4 8 16 6 2 0 1 0 Histopathology 71 54 0 0 14 3 0 0 0 0 Immunology 3 2 0 0 0 1 0 0 0 0 Infectious Diseases 2 0 0 0 1 1 0 0 0 0 Intensive Care Medicine 16 12 0 0 0 3 1 0 0 0
Medical Microbiology and Virology 45 36 0 1 8 0 0 0 0 0
Medical Oncology 13 6 0 2 3 0 0 1 1 0 Neurology 38 17 0 0 11 6 1 1 2 0 Neurosurgery 20 8 1 1 4 6 0 0 0 0 Nuclear Medicine 1 0 0 0 1 0 0 0 0 0 Obstetrics & Gynecology 308 88 12 27 64 94 0 3 10 10
Occupational Medicine 15 8 0 1 3 0 0 2 1 0
Old age Psychiatry 83 31 1 15 8 16 0 1 11 0 Ophthalmology 140 55 13 20 18 24 0 1 8 1 Otolaryngology 117 41 7 12 15 31 4 2 5 0 Pediatric Cardiology 5 4 0 0 1 0 0 0 0 0
198
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005 Table No 3. Medical Staff by Specialty and Grade (Cont…)
SPECIALTY TOTAL CONSULTANT ASSOCIATE SPECIALIST
STAFF GRADE
SPECIALIST REGISTRAR
SENIOR HOUSE
OFFICER
HOUSE OFFICER
HOSPITAL PRACTITIONER
CLINICAL ASSISTANT
OTHER STAFF
Pediatric Neurology 3 3 0 0 0 0 0 0 0 0 Pediatric Surgery 10 5 0 0 2 2 1 0 0 0 Pediatrics 432 121 29 54 64 148 7 0 3 6 Palliative Medicine 45 16 0 10 11 4 2 1 1 0 Plastic Surgery 36 10 0 0 14 12 0 0 0 0 Psychiatry of Learning Disability 40 13 0 5 3 8 0 5 5 1
Psychotherapy 5 1 0 0 0 3 0 0 1 0 Rehabilitation Medicine 15 5 0 1 1 2 0 0 6 0
Renal Medicine 44 8 3 5 13 9 5 0 0 1 Respiratory Medicine 74 25 0 2 35 10 2 0 0 0 Rheumatology 49 23 0 3 9 4 2 3 5 0 Traumatic & Orthopedic Surgery 269 93 10 30 46 77 5 1 1 6
Urology 79 28 3 6 14 16 7 0 2 3 Other 12 4 1 1 0 0 0 1 5 0
Dental Specialties 0 0 0 0 0 Dental Medical Specialties 5 4 0 0 1 0 0 0 0 0
Oral and Maxillofacial Surgery 92 24 6 9 8 28 0 1 16 0
Oral Surgery 5 1 1 2 0 0 0 0 1 0 Orthodontics 40 13 2 1 11 0 0 0 13 0 Pediatric Dentistry 8 3 0 1 1 2 0 0 1 0 Restorative Dentistry 59 10 7 9 3 7 0 0 23 0
Note: Only considered the 'Numbers' for each professional activity. Did not consider the whole time equivalents Source: Health Statistics and Analysis Unit, Wales Assembly Government,2005 [Accessed October 2007]
199
UK
(CONSOLIDATED DATA)
200
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN UK Table No 1. Total Physicians by Specialty and Gender SPECIALTY TOTAL MALE % FEMALE %
TOTAL PHYSICIANS 154,246 93,423 61 60,823 39 Anesthesiology 12,351 8,150 66 4,201 34 Cardiology 2,438 1,908 78 530 22 Dermatology 1,401 630 45 771 55 Emergency Medicine 5,652 3,540 63 2,112 37 General Physicians / General Practitioners / Family Doctors 40,720 23,885 59 16,835 41 General Surgery / Vascular Surgery 8,180 5,850 72 2,330 28 Internal Medicine 19,018 11,292 59 7,726 41 Medical Oncology 1,918 996 52 922 48
Neurology 1,266 917 72 349 28 Neurosurgery 649 562 87 87 13 Obstetrics and Gynecology 6,067 2,758 45 3,309 55 Ophthalmology 2,763 1,890 68 873 32 Orthopedic Surgery and Traumatology 6,021 5,265 87 756 13 Otolaryngology 2,047 1,616 79 431 21 Pathology 4,758 2,625 55 2,133 45 Pediatric & Pediatric Surgery 8,614 3,954 46 4,660 54 Physical Medicine, Rehabilitation and Rheumatology 1,578 936 59 642 41 Plastic Surgery 925 728 79 197 21 Psychiatry 11,594 6,590 57 5,004 43 Public Health / Community Medicine / Occupational Medicine 4,670 1,771 38 2,899 62 Radiology 3,894 2,546 65 1,348 35 Thoracic Surgery 855 752 88 103 12 Urology / Renal Failure Surgery 1,804 1,464 81 340 19 Other Specialties 1,598 799 50 799 50 Dental group 3,465 1,999 58 1,466 42
Note: The data points for England and Scotland are for the year 2006; the data points for Wales are for the year 2005 and for Northern Ireland the data is for the year 2007. The consolidated data tables are based on the latest available data for all these provinces, although they do not belong to the same year
201
Source:
1) IC (2007) NHS Hospital and Community Health Services: Medical and Dental Workforce Census England - 30 September 2006 - Detailed Results [internet], IC. Available from: <http://www.ic.nhs.uk/webfiles/publications/nhsstaff2006/med/Medical%20and%20Dental%20Detailed%20Results%202006.pdf> [Accessed September 2007]
2) Workforce Statistics; Health, Social Service and Public Safety Department, Statistics and Research, Medical Staff, 2007 [Accessed October 2007]. 3) ISD Scotland (2007) NHS Scotland Workforce Statistics - Table B5: HCHS staff by gender, contract type, specialty, NHS Board and Region [internet], ISD Scotland. Available from:
<http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=WFB05_HB_REG.xls&pContentDispositionType=inline> [Accessed September 2007]. 4) Health Statistics and Analysis Unit, Wales Assembly Government, 2005 [Accessed October 2007] 5) Stats Wales (2007) GP Headcount (gender, age group) [internet], stats Wales. Available from: <http://www.statswales.wales.gov.uk/TableViewer/tableView.aspx?ReportId=1617> [Accessed October
2007]
202
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN UK Table No 2. Total Physicians by Specialty and Age SPECIALTY TOTAL UNDER 35 35-44 45-54 55 AND OVER
TOTAL PHYSICIANS 154,072 52,356 45,020 36,082 20,614 Anesthesiology 12,368 4,305 4,135 2,608 1,319 Cardiology 2,438 1,018 795 413 213 Dermatology 1,401 330 476 370 226 Emergency Medicine 5,652 3,503 1,287 557 305 General Physicians / General Practitioners / Family Doctors 40,719 5,240 13,114 14,103 8,262 General Surgery / Vascular Surgery 8,180 4,384 1,880 1,228 689 Internal Medicine 13,234 6,129 3,413 2,270 1,422 Medical Oncology 1,918 764 620 319 216
Neurology 1,266 374 450 263 179 Neurosurgery 649 298 205 95 51 Obstetrics and Gynecology 6,067 2,377 1,913 1,171 606 Ophthalmology 2,763 757 943 667 396 Orthopedic Surgery and Traumatology 6,021 2,701 1,740 999 581 Otolaryngology 2,047 743 572 424 308 Pathology 4,758 1,218 1,378 1,411 751 Pediatric & Pediatric Surgery 8,614 3,963 2,362 1,471 818 Physical Medicine, Rehabilitation and Rheumatology 1,578 459 495 350 274 Plastic Surgery 925 409 310 144 62 Psychiatry 11,594 3,967 3,610 2,623 1,394 Public Health / Community Medicine / Occupational Medicine 4,670 876 1,250 1,640 904 Radiology 3,894 1,122 1,247 1,011 514 Thoracic Surgery 855 320 298 159 77 Urology / Renal Failure Surgery 1,804 702 533 388 182 Other Specialties 7,365 5,213 1,074 649 430 Dental group 3,292 1,186 920 749 437
203
Note: 1) The total in this table may not be equal to the total as in table 1, since the age break up for the dental group (n=173) in Northern Ireland is not available 2) The age group for one specialty in England is categorized as 'Unknown'. Hence, not included in the above table 3) The data points for England and Scotland are for the year 2006; the data points for Wales are for the year 2005 and for Northern Ireland the data is for the year 2007. The consolidated data tables are
based on the latest available data for all these provinces, although they do not belong to the same year Source:
1) The information centre,National Health Service, Department of Health, 2006 [Accessed October 2007]. 2) Workforce Statistics; Health, Social Service and Public Safety Department, Statistics and Research, Medical Staff, 2007. 3) ISD Scotland (2007) NHS Scotland Workforce Statistics - Table B6: HCHS staff by specialty by age group, NHS Board and Region [internet], ISD Scotland. Available from:
<http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=WFB06_HB_REG.xls&pContentDispositionType=inline> [Accessed September 2007]. 4) Health Statistics and Analysis Unit, Wales Assembly Government, 2005 [Accessed October 2007]
204
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN UK Table No 3. Medical Staff by Specialty and Grade
SPECIALTIES TOTAL
CONSULTANT (INCLUDING DIRECTOR OF PUBLIC HEALTH)
ASSOCIATE SPECIALIST
STAFF GRADE
REGISTRAR GROUP /
SPECIALIST REGISTRAR
SENIOR HOUSE
OFFICERS / FOUNDATION
YEAR 2
HOUSE OFFICERS /
FOUNDATION YEAR 1
CLINICAL MEDICAL OFFICER
SENIOR CLINICAL MEDICAL OFFICER
HOSPITAL PRACTITIONER/
CLINICAL ASSISTANT
GMP / GDP
GRADES1
GENERAL/ MEDICAL
PRACTITIONER
OTHER STAFF
TOTAL PHYSICIANS 113,369 39,674 3,306 7,144 21,919 28,055 5,955 85 11 3,958 685 102 2,475
Anesthesiology 12,369 5,752 319 886 2,666 2,491 140 0 0 92 12 1 10
Cardiology 2,438 897 39 106 697 448 107 0 0 133 8 0 2Dermatology 1,401 543 77 55 233 97 4 0 0 340 40 11 2Emergency Medicine 5,652 866 133 633 889 2,791 111 0 0 165 34 11 18
General Physicians / General Practitioners / Family Doctors
N.A N.A N.A N.A N.A N.A N.A N.A N.A N.A N.A N.A N.A
General Surgery / Vascular Surgery
8,180 2,189 169 332 1,517 1,826 1,972 1 0 151 13 1 8
Internal Medicine 19,002 4,832 300 742 2,982 6,110 2,629 7 0 1,101 230 30 40
Medical Oncology 1,918 832 29 87 571 315 32 0 0 52 1 0 0
Neurology 1,267 668 17 22 287 214 12 0 0 45 2 0 0
Neurosurgery 649 224 4 6 231 173 11 0 0 0 0 0 0Obstetrics and Gynecology 6,068 1,838 154 331 1,537 1,928 62 2 1 156 28 0 31
Ophthalmology 2,763 999 229 329 524 514 12 4 0 135 9 0 6Orthopedic Surgery and Traumatology
6,021 2,009 222 344 1,357 1,756 248 0 0 73 5 0 6
Otolaryngology 2,047 729 108 154 394 553 29 0 0 74 1 5 0Pathology 4,759 2,902 100 95 1,222 334 20 0 0 59 20 5 3
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PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN UK Table No 3. Medical Staff by Specialty and Grade (Cont…)
SPECIALTIES TOTAL
CONSULTANT (INCLUDING DIRECTOR OF PUBLIC HEALTH)
ASSOCIATE SPECIALIST
STAFF GRADE
REGISTRAR GROUP /
SPECIALIST REGISTRAR
SENIOR HOUSE
OFFICERS / FOUNDATION
YEAR 2
HOUSE OFFICERS /
FOUNDATION YEAR 1
CLINICAL MEDICAL OFFICER
SENIOR CLINICAL MEDICAL OFFICER
HOSPITAL PRACTITIONER/
CLINICAL ASSISTANT
GMP / GDP
GRADES1
GENERAL/ MEDICAL
PRACTITIONER
OTHER STAFF
Pediatric & Pediatric Surgery
8,614 2,603 326 645 2,033 2,745 169 2 1 51 11 5 23
Physical Medicine, Rehabilitation and Rheumatology
1,578 765 29 74 341 178 43 0 0 131 16 0 1
Plastic Surgery 925 300 24 20 288 277 9 0 0 6 2 0 0
Psychiatry 11,595 4,597 521 1,439 1,206 3,228 52 2 0 427 90 4 30Public Health / Community Medicine / Occupational Medicine
4,674 1,405 204 349 366 231 7 61 9 120 81 23 1,819
Radiology 3,894 2,523 30 32 1,216 72 2 0 0 18 0 0 0Thoracic Surgery 855 294 6 19 284 230 14 0 0 4 0 0 3
Urology / Renal Failure Surgery 1,804 663 73 108 391 369 168 0 0 26 2 0 4
Other Specialties 1,598 401 50 75 284 584 76 5 0 101 8 8 6
Dental group 3,298 843 144 261 404 589 26 0 0 497 72 0 462
Source:
1. IC (2007) NHS Hospital and Community Health Services: Medical and Dental Workforce Census England - 30 September 2006 - Detailed Results [internet], IC. Available from: <http://www.ic.nhs.uk/webfiles/publications/nhsstaff2006/med/Medical%20and%20Dental%20Detailed%20Results%202006.pdf> [Accessed September 2007]
2. Workforce Statistics; Health, Social Service and Public Safety Department, Statistics and Research, Medical Staff, 2007. 3. ISD Scotland (2007) NHS Scotland Workforce Statistics - Table B9: HCHS medical and dental staff by specialty, grade, NHS Board and Region [internet], ISD Scotland. Available from:
<http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=WFB09_HB_REG.xls> [Accessed September 2007]. 4. Health Statistics and Analysis Unit, Wales Assembly Government, 2005 [Accessed October 2007]
206
15. USA
207
15.1. Introduction to the United States of America
The United States of America (US or USA) is the world's third or fourth largest nation by
total area, before or after the People's Republic of China, depending on how two
territories disputed by China and India are counted. Including only land area, the United
States is third in size behind Russia and China, just ahead of Canada. The continental US
stretches from the Atlantic Ocean to the Pacific Ocean and from Canada to Mexico and
the Gulf of Mexico. Alaska is the largest state in area. Separated by Canada, it touches
the Pacific and Arctic Oceans. Hawaii occupies an archipelago in the Pacific, southwest
of North America. The commonwealth of Puerto Rico, the largest and most populous US
territory, is in the northeastern Caribbean. With a few exceptions, such as the territory of
Guam and the westernmost portions of Alaska, nearly all of the country lies in the
western hemisphere (Figure 19).
Figure 19: USA political map
Source: www.wikipedia.org
208
According to the World Health Statistics (2007), there were 298,213,000 inhabitants in
the US in 2005. In the same year, the life expectancy at birth was estimated at 75 years
for males and 80 years for females. On October 17, 2006, the US population was
estimated by the US Census Bureau to be 300,000,000. The US population included an
estimated 12 million unauthorized migrants, of whom an estimated 1 million were
uncounted by the Census Bureau. The overall growth rate is 0.89%, compared to 0.16%
in the European Union. The birth rate of 14.16 per 1,000 is 30% below the world average,
while higher than any European country except for Albania and Ireland. In 2006, 1.27
million immigrants were granted legal residence. Mexico has been the leading source of
new US residents for over two decades; since 1998, China, India, and the Philippines
have ranked in the top four among migrants’ countries of origin every year. The United
States is the only industrialized nation in which large population increases are projected.
15.2. The US healthcare system
Unlike most other major markets, there is no government-led scheme providing access to
healthcare for all residents. The healthcare system is fragmented, with public healthcare
schemes (Medicare, Medicaid and the State Children’s Health Insurance Program)
providing basic healthcare coverage for over 80 million people and private insurance
covering around 200 million including those supplementing their Medicare coverage
(Datamonitor, Macro-environmental healthcare issues in the US, 2004). There are over
43 million uninsured people in the US, as fewer employees are being covered by
employer-funded health schemes. The following figure (Figure 20) shows the healthcare
structure in the US.
209
Figure 20: Healthcare structure in the US
Source: internal secondary research D A T A M O N I T O R
15.3. Healthcare insurance
Medicare is the federal health insurance program that covers the elderly (those aged 65
and over), people with certain disabilities; and patients with end-stage renal disease.
Medicare serves all eligible beneficiaries without regard to income or health status.
Medicare recently underwent a significant reform and now provides prescription drug
coverage for outpatients for the first time. Medicaid is the joint federal and state-run
program that provides health coverage to low-income families with dependent children,
pregnant women, people with disabilities and the indigent population. The state’s
Children’s Health Insurance Programs (known as CHIPs and other names in various
states) provide benefit packages for over 5 million children under age 19 who do not
qualify for Medicaid.
The majority of the US population has private health insurance, virtually all provided by
Managed Care Organizations (MCOs) which include Health Maintenance Organizations
(HMOs), Preferred Provider Organizations (PPOs), Point of Service (POS) plans and
Provider-Sponsored Organizations (PSO). MCO, an entity that finances and manages
210
healthcare delivery through networks of doctors, hospitals and specialty providers,
dominates the private health insurance market, covering 95% of employees. The
following table (Table 29) gives a description of the leading categories of private health
insurance plans in the US.
Table 29: Leading Types of Private Insurance in the US
Type Sub-Type Description
Tra
ditio
nal
Indemnity
Reimburses patients as expenses are incurred High freedom of choice, but high OOP costs. Leading form of insurance from post WWII to beginning of 1990s but relatively rare now.
Les
s R
estr
ictiv
e
Preferred Provider Organization (PPO)
Coverage is provided through a network of contracted fee-for-service providers. Members are free to seek service outside network but will incur significantly higher OOP costs
Point of Service HMO PP hybrid where members do not have to pre—enroll with physicians
Health Maintenance Organization (HMO)
Network Model
HMO contracts with multiple physician groups
Individual Practice Association
Independent or small physician groups that form collectives for purposes of attracting HMO patients
Group Model HMO contracts with a single-multi specialty physician group Payment is usually on a capitated basis
L
ess
Exp
ensi
ve
Man
aged
Car
e
HMOs are comprehensive services that assume responsibility for financing and delivering care. Members must pre-select a primary care physician and non-emergency services require prior authorization Payments for within network care are covered without reliance on OOP-reimbursement system
Staff Model Physicians are employees of HMO Services are delivered through HMO owned facilities
Source: internal secondary research D A T A M O N I T O R
A patient’s cost burden or care depends on the type of program, his or her state of health,
and the health of any dependants. Over 70% of the population under 65 years of age has
private health insurance, with more than 90% of private coverage obtained through
employers. Around 16 million people purchase their own health insurance (internal
secondary research). The following table (Table 30) shows population coverage for
public and private insurance plans in 2003 and 2004. As indicated, employment-based
211
plans are the most common among healthcare insurance plans. However, the percentage
of people covered by employment-based health insurance fell between 2003 and 2004.
Table 30: Source of Health Coverage Type of Coverage 2003 2004 Change% Employment Based 60.4% 59.8% -1.0% Direct Purchase 9.2% 9.3% 1.1% Total Private 68.6% 68.1% -0.7% Medicare 13.7% 13.7% 0.0% Medicaid 12.4% 12.9% 4.0% Military 3.5% 3.7% 5.7% Total Public 26.6% 27.2% 2.3% No Coverage 15.7% 15.7% 0.0% Note that percentages do not add up to 100% due to the possibility for coverage under multiple plans Source: internal secondary research D A T A M O N I T O R
Rising costs have led to a significant curtailment in the provision of employee-based
health insurance. Only 60% of private firms offered health benefits in 2005 compared to
69% in 2000. The majority of private coverage is obtained through employers, with the
premiums shared between employer and employee. Around 16% of single coverage
premiums and 27% of family premiums are paid by the employees, resulting in a
significant cost burden for the employers. The cost of providing healthcare insurance is
therefore, one of the most important problems affecting US companies.
15.4. Service delivery
Access to care is determined by the type of health insurance coverage, with managed care
being the most restricted system. Whether referral by a primary care physician is required
for patient access to a specialist depends on the payer:
o Medicare beneficiaries can choose to visit healthcare professionals participating in
the federal scheme;
212
o In general, state Medicaid plans must allow patients freedom of choice among
healthcare providers participating in Medicaid. States may place limits on a
Medicaid service based on criteria such as medical necessity or utilization control
(e.g., a limit on the number of covered physician visits or prior authorization
before delivery of a service). Healthcare delivery in Medicaid programs
increasingly relies on managed care, with 57% of Medicaid beneficiaries enrolled
in some form of managed care plan. Medicaid HMOs are typically closed-
delivery systems that are tightly regulated by care management (restricted
networks and pre-authorization requirements) in return for assured access.
Medicaid beneficiaries in fee-for-service programs are less likely to receive
regular medical or preventive care than the commercially insured population;
o Patients with fee-for-service health plans can choose any physician they wish and
do not need to obtain a referral from a primary care physician prior to consulting a
specialist. Patients can also go to any hospital, typically paying a deductible and a
co-insurance, which will vary according to insurance plans. There is no formal co-
ordination of medical care by a physician and the insurance plan neither reviews
nor denies use of services. Pre-authorization is not required to obtain services.
Fee-for-service plans may encourage physicians to over-treat patients since they
are paid for services rendered and there are no incentives to keep patients healthy;
o Managed care plans, on the other hand, have a greater role in determining what
services patients receive and may also influence how the doctor practices. The
extent of control over access to healthcare varies according to the type of plan,
with HMOs having the most influence over the way in which doctors and
hospitals provide care.
213
The following table (Table 31) describes access to healthcare in the US by type of health
plan.
Table 31: Access to healthcare providers according to different health plans
HMO PPO POS
Choice of doctor
Must be from the HMOs network. The primary care physician is the primary contact for all health services and manages care by coordinating necessary services
No restrictions. However, if a doctor does not accept the insurance plan, he is considered out-of-network and the patient won’t get coverage for the visit
To have care paid for, patient must select a doctor from the POS network. The alternative is to go out-of-network at a higher price
Access to specialists Referral from primary care doctor required
Direct access, without need for referral
Referral from the primary care doctor is required to stay in network (and pay a small fee), but patients can opt to see any specialist without a referral for a higher price.
HMO = health maintenance organization; PPO = preferred provider organization; POS = point-of-service
Source: internal secondary research D A T A M O N I T O R
15.5. Healthcare financing and expenditure
Total health spending accounted for 15.3% of Gross Domestic Product (GDP) in the
United States in 2005, the highest share in the OECD countries (OECD Health data,
2007). The United States also ranks far ahead of other OECD countries in terms of total
health spending per capita, with spending of $6,401 (adjusted for purchasing power
parity), more than twice the OECD average of $2,759 in 2005. Between 2000 and 2005,
health spending per capita in the United States increased, in real terms, by 4.4% per year
on average. Differences in health spending across countries may reflect differences in
price, volume and quality of medical goods and services consumed. The following table
(Table 32) shows the key health expenditure indicators in 2005.
214
Table 32: Key US health expenditure indicators, 2005
Indicator Value (year)
Total expenditure on health as percentage of gross domestic product 15.3% (2005) Public expenditure on health as percentage of total expenditure on health 45.1% (2005) Private expenditure on health as percentage of total expenditure on health 37% (2005) Per capita total expenditure on health (adjusted for purchasing power parity) $6,401 (2005)
Source: OECD Health data, 2005 D A T A M O N I T O R
According to the OECD Health data (2007), only 45.1% of health spending is funded by
government revenues in the US. On the other hand, private insurance accounts for 37% of
total health spending in the US, by far the largest share among OECD countries. The
following table (Table 33) shows the sources of healthcare funds in 2004. Although the
US doesn’t have a universal national health insurance program, about 45% of
expenditures came from public sources in 2004.
Table 33: Sources of US health spending, 2004
Source Total $ billion % of Total % of Growth Out of Pocket $235.7 12.5% 5.5% Private insurance $658.6 35.1% 8.6% Other Private $136.5 7.3% 6.8% Total Private $1,030.80 54.9% 7.6% Medicare $309 16.5% 8.9% Medicaid $202.7 15.6% 8% Other Public $245.8 13.1% 7.5% Total Public $847.5 45.1% 8.2% Combined Total $1,878.30 100% 7.9%
Source: : internal secondary research D A T A M O N I T O R
The following table (Table 34) shows distribution of healthcare funds in 2004. As
indicated, professional services and hospital care represent by far the largest components.
The US pharmaceutical market is the world’s largest by a wide margin, but Americans
spend a relatively low portion (10%) of the total health budget on drugs compared to
other countries.
215
Table 34: Destination of Health Spending, 2004
Destination % Total Spending % Growth
Hospital care 30.4% 8.6% Professional Services 31.3% 8.1% Home Health & Nursing Homes 8.4% 6.6% Prescription Drugs 10% 8.3% Administration 7.3% 9.4% Other 12.6% 5.2% Total 100.00% 7.90%
Source: internal secondary research D A T A M O N I T O R
The share of health expenditure spent on pharmaceuticals in the US increased from 8.9%
of total health spending in 1995 to 12.4% in 2005 (OECD Health data, 2007). The US
was nonetheless the top spender on pharmaceuticals in 2005, with spending of $792 per
capita. The percentage of total healthcare spending attributable to pharmaceuticals in the
US increased by 78.6% from 1994 to 2004 (Kaiser Family Foundation: Trends and
Indicators in the Changing Health Care Marketplace, 2005), and was approximately $230
billion in 2005. Pharmaceutical products are widely used in the US, with an estimated
51% of the population taking prescription drugs on a daily basis and 27% taking three or
more drugs daily (USA Today/Kaiser Family Foundation/Harvard School of Public
Health: Health Care Costs Survey, 2005). Faced with such trends, the US government
and healthcare providers have put in place a number of policies and strategies aimed at
reducing pharmaceutical expenditure.
15.6. Resources
Despite the relatively high level of health expenditure in the United States, it had only 2.4
practicing physicians per 1,000 population in 2005 as indicated in the table below. There
were 7.9 nurses per 1,000 population in 2002 (latest year available). The number of acute
care hospital beds in the United States in 2005 fell to 2.7 per 1,000 population, from 4.4
beds per 1,000 population in 1980. This decline has coincided with a reduction in average
length of stays in hospitals and an increase in day-surgery patients. The following table
(Table 35) gives the absolute number and density of physicians and nurses in the recent
216
years. For a complete review of the most up to date physician statistics, please refer to the
US physician statistics section of this report.
Table 35: Physicians and Nurses
Indicator Value (year) Physicians (number) 730,801 (2000) Physicians (density per 1,000 population) 2.4 (2005) Nurses (number) 2, 669, 603 (2000) Nurses (density per 1, 000 population) 7.9 (2002)
Source: OECD Health Data, 2007 D A T A M O N I T O R
15.7. The US pharmaceutical market
The US pharmaceutical market generated an estimated $230 billion in sales in 2005 (IMS
Health, 2006). Of that, approximately 10% was generic sales, giving the US generics
market a sales value of $24 billion in 2005. In volume terms, however, the generics
market dominates, accounting for 56% of all prescriptions dispensed in the US. The
following table (Table 36) shows the share of market held by original brands, branded
generic and true generics. Generics experienced dramatic growth in 2005, with true
generics reaching 50.1% of all prescriptions dispensed and branded generics accounting
for an additional 9.1% (internal secondary research). During 2005, $17 billion in branded
product sales were exposed to generic competition for the first time. The biggest brands
to lose exclusivity were Allegra (fexofenadine), Duragesic (fentanyl), Zithromax
(azithromycin) and Rochepin (ceftriaxone). Using 2005 sales figures, Datamonitor
research estimates that $19.5 billion are at risk of losing exclusivity in 2007; $17 billion
in 2008 and $6.5 billion in 2009.
217
Table 36: Generic and branded trends in the US, 2004-2005
Percent of Prescription Value 2004 2005 CAGR
Generics 7.80% 8.90% 2.7% Branded Generics 9.60% 9.80% 1.4% Combined Generics 17.40% 18.70% 2% Brands 82.60% 81.30% -0.4%
Percent of prescription volume 2004 2005 CAGR
Generics 43.60% 50.10% 3.9% Branded Generics 10.60% 9.10% -4.1% Combined Generics 54.20% 59.20% 2.3% Brands 45.80% 40.80% -2.7%
Source: internal secondary research D A T A M O N I T O R
The data in the following table (Table 37) reflects sales activity by therapeutic category
in 2005. Cytostatics (oncology) drugs represented the strongest growth category.
218
Table 37: US retail sales by therapeutic category, 2005 Category $m % Change Cardiovascular 34,383 8% Central Nervous System 41,718 2% Alimentary/Met. 24,814 3% Respiratory 17,186 9% Anti-Infectives 14,287 6% Musculoskeletal 10,453 -11% Genitourinary 10,881 3% Cytostatics 8,239 15% Blood Agents 5,543 9% Dermatologicals 4,615 -3% Sensory Organs 3,212 7% Diagnostic Agents 2,731 10% Systemic Hormones 2,827 8% Miscellaneous 1,588 12% Hospital Solutions 4 -4% Parasitology 232 12% Total 182,713 6%
Source: internal secondary research D A T A M O N I T O R
The top three pharmaceutical companies in the US in 2005 by US sales were Pfizer,
GlaxoSmithKline (GSK) and Johnson & Johnson (Pharma Handbook 2006, VOI
Consulting). R&D investments by Pharmaceutical Research and Manufacturers of
America (PhRMA) member companies amounted to $39.4 billion in 2005 (up from $37
billion in 2004), which is equivalent to 19.2% of domestic drug sales. Total investments
in biotechnology and pharmaceutical R&D by both PhRMA member companies and non-
members totaled $51.3 billion. The average time for eventually approved drugs to spend
in clinical trials is seven years. The rate at which the 10 top US pharmaceutical
companies initiated clinical trials for new drugs rose by 52% in the 2003–05 period as
compared with 1998–2002. At the beginning of 2006, the top 46 companies had 1,270
products in preclinical or clinical testing. 144 were in Phase III; 250 were in Phase II.
Cross-border trade declined from $491 million in 2004 to $351 in 2005. A number of
factors, including increased focus on drug safety, patent expirations of a number of
219
leading drugs, the strengthening of the Canadian versus the US dollar and restricted
availability of supplies were implicated in this slowdown.
220
15.8. Bibliography
o World Health Organization (2007), World health statistics [Internet]. Available
from:
<http://www.who.int/whosis/database/core/core_select_process.cfm?country=usa
&indicators=selected&language=en> [Accessed October 2007].
o World Health Organization (2007), World health statistics [Internet]. Available
from:
<http://www.who.int/whosis/database/core/core_select_process.cfm?country=us&
indicators=healthpersonnel> [Accessed October 2007].
o Datamonitor (2004), Macro-environmental healthcare issues in the US, 2004.
o OECD data (2007), OECD United States Health data 2007 [Internet] Available
from: < http://www.oecd.org/dataoecd/46/2/38980580.pdf> [Accessed October
2007].
o Datamonitor (2006), Global Generics Guide: Part 2 - Benchmarking country
markets and strategic issues, June 2006, DMHC 2216.
221
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.1. Total Physicians by Specialty and Gender SPECIALTY TOTAL MALE % FEMALE %
TOTAL PHYSICIANS 902,053 657,140 73 244,913 27 Aerospace Medicine 468 434 93 34 7 Allergy/ Immunology 4,112 3,031 74 1,081 26 Anesthesiology 40,494 31,492 78 9,002 22 Cardiovascular Disease 22,349 20,210 90 2,139 10 Child Psychiatry 7,234 3,952 55 3,282 45 Colon/ Rectal Surgery 1,291 1,133 88 158 12 Dermatology 10,593 6,519 62 4074 38 Diagnostic Radiology 24,231 18,858 78 5373 22 Emergency Medicine 29,144 22,687 78 6457 22 Family Medicine 81,701 54,307 66 27394 34 Forensic Pathology 672 444 66 228 34 Gastroenterology 12,017 10,670 89 1347 11 General Practice 11,049 8,950 81 2099 19 General Preventive Medicine 2,211 1,392 63 819 37 General Surgery 37,857 32,387 86 5470 14 Internal Medicine 154,002 105,987 69 48015 31 Medical Genetics 498 259 52 239 48 Neurological Surgery 5,440 5,111 94 329 6 Neurology 14,331 10,787 75 3544 25 Nuclear Medicine 1,500 1,202 80 298 20 Obstetrics/ Gynecology 42,600 24,507 58 18093 42 Occupational Medicine 2,626 2,110 80 516 20 Ophthalmology 18,870 15,498 82 3372 18 Orthopedic Surgery 24,140 23,039 95 1101 5 Otolaryngology 9,917 8,757 88 1160 12 Pathology-Anatomic/ Clinical 19,339 12,795 66 6544 34 Pediatric Cardiology 1,842 1,320 72 522 28 Pediatrics 72,288 33,875 47 38,413 53
222
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.1. Total Physicians by Specialty and Gender (Cont…) SPECIALTY TOTAL MALE % FEMALE %
Physical Medicine & Rehabilitation 7,685 5,047 66 2638 34 Plastic Surgery 7,021 6,202 88 819 12 Psychiatry 41,598 27,663 67 13935 33 Public Health & General Preventive Medicine 1,501 1,051 70 450 30 Pulmonology 10,074 8,574 85 1500 15 Radiation Oncology 4,378 3,327 76 1051 24 Radiology 8,813 7,473 85 1340 15 Thoracic Surgery 4,897 4,722 96 175 4 Transplant Surgery 125 115 92 10 8 Urological Surgery 10,676 10,120 95 556 5 Vascular Medicine 21 16 76 5 24 Other Specialties 5,350 4,410 82 940 18 Unspecified 7,483 5,146 69 2337 31 Inactive 99,823 87,383 88 12440 12 Not Classified 39,304 23,836 61 15468 39 Address Unknown 488 342 70 146 30
Source: American Medical Association, 2007, Physician Characteristics and Distribution in the US, 2007 Edition
223
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No 2. Total Physicians by Specialty and Age SPECIALTY TOTAL UNDER 35 35-44 45-54 55-64 65 AND OVER
TOTAL PHYSICIANS 902,053 140,093 212,050 222,469 157,596 169,845 Aerospace Medicine 468 21 49 157 127 114 Allergy/ Immunology 4,112 347 783 1,219 1,116 647 Anesthesiology 40,494 5,130 11,460 13,733 6,947 3,224 Cardiovascular Disease 22,349 1,970 5,281 7,404 5,091 2,603 Child Psychiatry 7,234 563 2,001 2,207 1,546 917 Colon/ Rectal Surgery 1,291 75 399 410 289 118 Dermatology 10,593 1,683 2,569 2,762 2,380 1,199 Diagnostic Radiology 24,231 4,203 6,485 7,291 4,747 1,505 Emergency Medicine 29,144 6,546 8,234 8,022 5,162 1,180 Family Medicine 81,701 13,638 24,083 25,410 13,087 5,483 Forensic Pathology 672 33 177 224 133 105 Gastroenterology 12,017 1,174 3,194 3,948 2,718 983 General Practice 11,049 57 345 1,953 3,443 5,251 General Preventive Medicine 2,211 217 702 726 334 232 General Surgery 37,857 8,120 8,923 8,519 7,140 5,155 Internal Medicine 154,002 31,233 42,131 42,895 25,840 11,903 Medical Genetics 498 56 127 153 109 53 Neurological Surgery 5,440 803 1,416 1,406 1,027 788 Neurology 14,331 1,651 3,690 4,431 3,126 1,433 Nuclear Medicine 1,500 108 290 407 415 280 Obstetrics/ Gynecology 42,600 6,423 11,034 11,390 8,738 5,015 Occupational Medicine 2,626 11 200 984 791 640 Ophthalmology 18,870 2,010 4,549 5,329 4,328 2,654 Orthopedic Surgery 24,140 3,766 5,836 6,454 5,073 3,011 Otolaryngology 9,917 1,419 2,575 2,512 2,032 1,379 Pathology-Anatomic/ Clinical 19,339 1,937 4,256 5,580 4,259 3,307 Pediatric Cardiology 1,842 244 610 492 280 216 Pediatrics 72,288 16,118 20,556 18,224 11,856 5,534 Physical Medicine & Rehabilitation 7,685 1,122 2,607 2,260 1,133 563
224
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No 2. Total Physicians by Specialty and Age (Cont…) SPECIALTY TOTAL UNDER 35 35-44 45-54 55-64 65 AND OVER
Plastic Surgery 7,021 699 1,728 2,101 1,665 828 Psychiatry 41,598 4,193 7,697 11,311 10,126 8,271 Public Health & General Preventive Medicine 1,501 2 67 419 435 578 Pulmonology 10,074 1,130 2,925 3,145 2,178 696 Radiation Oncology 4,378 569 1,204 1,357 864 384 Radiology 8,813 462 2,350 1,806 2,044 2,151 Thoracic Surgery 4,897 169 1,128 1,516 1,196 888 Transplant Surgery 125 38 60 14 13 Urological Surgery 10,676 1,202 2,477 2,610 2,672 1,715 Vascular Medicine 21 7 4 7 3 Other Specialties 5,350 98 526 1,347 1,474 1,905 Unspecified 7,483 3,132 1,760 1,346 724 521 Inactive 99,823 52 1,317 4,542 8,972 84,940 Not Classified 39,304 17,703 14,262 4,399 1,846 1,094 Address Unknown 488 4 2 4 112 366 Source: American Medical Association, 2007, Physician Characteristics and Distribution in the US, 2007 Edition
225
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.3. Total Physicians by Specialty and Professional Activity
PATIENT CARE
HOSPITAL BASED OTHER PROFESSIONAL ACTIVITY
SPECIALTY TOTAL TOTAL PATIENT
CARE
OFFICE BASED RESID./
FELLOWS PHYS. STAFF ADMIN. MED.
TEACH. RESEARC
H OTHER
TOTAL PHYSICIANS 902,053 718,473 563,225 95,391 59,857 14,997 10,223 14,471 4,274 Abdominal Radiology 36 35 10 24 1 1 Abdominal Surgery 118 106 98 8 6 3 2 1 Addiction Medicine 212 168 121 47 24 4 7 9 Addiction Psychiatry 249 235 163 41 31 6 4 4
Adolescent Medicine (Internal Medicine) 13 10 9 1 2 1 Adolescent Medicine Pediatrics) 451 362 238 51 73 34 35 17 3 Adult Reconstructive Orthopedics 206 202 163 27 12 3 1 Aerospace Medicine 468 274 157 117 149 5 27 13 Allergy 783 725 708 17 15 6 29 8 Allergy & Immunology 2,984 2,800 2,452 224 124 27 28 117 12 Anatomic Pathology 1,012 734 544 190 32 55 126 65 Anatomic/Clinical Pathology 14,983 13,154 9,142 2,178 1,834 494 257 464 614
Anesthesiology 38,307 37,198 30,046 4,105 3,047 281 506 239 83 Blood Banking / Transfusion Medicine 508 354 271 38 45 100 11 25 18 Cardiothoracic Radiology 1 1 1 Cardiovascular Disease 22,349 20,965 17,519 2,004 1,442 283 323 707 71 chemical Pathology 32 14 13 1 6 3 3 6 Child and Adolescent Psychiatry 7,234 6,725 5370 582 773 211 140 126 32 Child Neurology 1,239 1,095 795 162 138 20 41 77 6 Clinical and Laboratory Dermatological Immunology 2 2 2
Clinical and Laboratory Immunology (Internal Medicine) 7 5 4 1 1 1
Clinical and Laboratory Immunology (Pediatrics) 2 1 1 1
226
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
HOSPITAL BASED OTHER PROFESSIONAL ACTIVITY
SPECIALTY TOTAL TOTAL PATIENT
CARE
OFFICE BASED
RESID./ FELLOW
S
PHYS. STAFF ADMIN. MED.
TEACH. RESEARC
H OTHER
Clinical Biochemical Genetics 8 3 3 5 Clinical Cardiac Electrophysiology 789 771 621 118 32 3 6 8 1 Clinical Cytogenetics 6 4 1 3 2 Clinical Genetics 102 77 53 24 7 8 9 1 Clinical Liboratorv lrnmunoIn’ (Allergy & lmniunoInj) 48 42 37 5 1 2 2 1
Clinical Molecular Genetics 10 2 2 1 6 1 Clinical Neurophysiology 569 560 425 122 13 2 4 3 Clinical Pathology 545 286 207 79 117 23 93 26 Clinical Pharmacology 349 55 42 13 60 15 210 9 Colon & Rectal Surgery 1,290 1262 1,155 42 65 6 13 6 3
Cosmetic Surgery 55 55 54 1 Craniofacial Surgery 7 7 4 2 1 Critical Care Medicine (Anesthesiology) 432 415 339 46 30 4 9 2 2 Critical Care Medicine (Internal Medicine) 1,304 1,203 896 107 200 33 42 24 2
Critical Care Medicine (Obstetrics & Gynecology) 5 2 2 1 2
Cytopathology 591 574 466 81 27 3 7 3 4 Dermatologic Surgery 104 104 98 6 Dermatology 10,570 10,302 8,793 1,057 452 54 82 115 17
Dermatopatbology 457 423 339 54 30 2 5 5 22 Developmental-Behavioral Pediatrics 36 36 3 31 2 Diabetes 334 225 205 20 15 10 80 4 Diagnostic Radiology 24,230 23,489 17,618 3,923 1,948 146 241 126 228 Emergency Medicine 28,799 27708 19,930 3832 3946 659 286 79 67 Endocrinology, Diabetes and Metabolism 4,896 4,050 3,252 431 367 125 135 563 23
227
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
HOSPITAL BASED OTHER PROFESSIONAL ACTIVITY
SPECIALTY TOTAL TOTAL PATIENT
CARE
OFFICE BASED
RESID./ FELLOW
S
PHYS. STAFF ADMIN. MED.
TEACH. RESEARC
H OTHER
Endovascular Surgical Neuroradiology 4 3 3 1 Epidemiology 32 4 2 2 3 1 15 9 Facial Plastic Surgery 375 371 354 1 16 3 1 Family Medicine 80,809 77863 65,006 7,898 4,959 1,219 1391 181 155 Family Practice/ Psychiatry 43 43 43 Foot and Ankle, Orthopedics 59 59 45 10 4 Forensic Pathology 672 475 413 35 27 44 10 9 134
Forensic Psychiatry 291 268 183 50 35 8 1 14 Gastroenterology 12,017 11,366 9,742 994 630 118 166 346 21 General Practice 11,049 10,638 9,347 1,291 229 26 42 114 General Preventive Medicine 2,147 1681 1209 260 212 230 38 147 51 General Surgery 31,485 30,535 20894 7406 2,235 399 264 172 115 Geriatric Medicine (Family Practice) 442 402 326 43 33 18 18 2 2 Geriatric Medicine (Internal Medicine) 2,912 2,611 1,948 284 379 124 67 104 6 Geriatric Psychiatry 706 684 521 89 74 8 7 7
Gynecology 2392 2282 2188 94 39 38 17 16 Gynecological Oncology 468 431 360 71 10 18 8 1 Hand Surgery 1,471 1,435 1,378 57 7 19 4 6 Hand Surgery (Orthopedics) 81 81 81 Hand Surgery (Plastic Surgery) 13 13 13 Hand Surgery (Surgery) 9 9 9 Head & Neck Surgery 245 223 197 26 5 11 5 1 Hematology (Internal Medicine) 2,301 1,745 1,405 65 275 85 83 378 10
Hematology (Pathology) 458 440 335 71 34 2 3 9 4 Hematology/ Oncology 3,923 3,803 2,657 964 182 14 22 76 8 Hepatology 96 75 59 16 2 8 11
228
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
HOSPITAL BASED OTHER PROFESSIONAL ACTIVITY
SPECIALTY TOTAL TOTAL PATIENT
CARE
OFFICE BASED
RESID./ FELLOW
S
PHYS. STAFF ADMIN. MED.
TEACH. RESEARC
H OTHER
Hospitalist 8 7 3 4 1 Immunology 297 63 47 16 24 13 190 7 Infectious Disease 6,191 4905 3,656 618 631 265 234 745 42 Internal Medicine 112,934 107,738 78801 20639 8,298 2031 1,227 1,553 385 Internal Medicine (Preventive Medicine) 16 16 16 Internal Medicine/ Dermatology 1 1 1 Internal Medicine/ Family Practice 14 14 14
Internal Medicine/Emergency Medicine 88 88 88 Internal Medicine/Neurology 12 12 12 Internal Medicine/Psychiatry 100 100 100 Internal Medicine/Pediatrics 3,718 3666 2,200 1,347 119 6 29 13 4 Interventional Cardiology 851 842 628 188 26 4 5 Legal Medicine 181 52 46 6 45 8 5 71 Maternal & Fetal Medicine 590 498 355 143 24 46 18 4 Medical Genetics 372 273 174 63 36 13 15 67 4
Medical Management 302 21 20 1 263 4 6 8 Medical Microbiology 63 42 32 4 6 7 3 9 2 Medical Oncology 5,503 4,730 4,097 182 451 161 59 534 19 Medical Toxicology (Emergency Medicine) 61 58 26 30 2 1 1 1
Medical Toxicology (Pediatrics) 2 2 2 Medical toxicology (Preventive Medicine) 11 9 5 4 2
Molecular Genetic Pathology (Pathology) 4 4 4
Musculoskeletal Oncology 64 61 49 10 2 3
229
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
HOSPITAL BASED OTHER PROFESSIONAL ACTIVITY
SPECIALTY TOTAL TOTAL PATIENT
CARE
OFFICE BASED
RESID./ FELLOW
S
PHYS. STAFF ADMIN. MED.
TEACH. RESEARC
H OTHER
Musculoskeletal Radiology 45 33 12 Neonatal-Perinatal Medicine 4008 3,590 2,592 450 548 88 105 210 15 Nephrology 7,175 6,526 5,410 700 416 129 122 383 15 Neurodevelopment Disabilities (Psychiatry & Neurology) 4 4 1 2 1
Neurodevelopmental Disabilities (Pediatrics) 1 1 1
Neurological Surgery 5379 5,219 4112 803 304 38 48 43 31
Neurology 12508 11,353 9,179 1,248 926 176 216 691 72 Neurology/Diagnostic Radiology/Neuroradiology 25 22 12 9 1 1 1 1
Neuropathology 360 238 178 28 32 7 32 73 10 Neuropsychiatry 1 1 1
Neuroradiology 1,556 1,521 1,240 182 99 2 19 7 7 Nuclear Cardiology 3 2 1 1 1 Nuclear Medicine 1,500 1,338 979 124 235 50 29 62 21 Nuclear Radiology 142 136 119 6 11 1 1 4 Nutrition 165 94 86 8 12 6 44 9 Obstetrics 232 211 184 27 5 11 5 Obstetrics & Gynecology 38,285 37,317 31,066 4,236 2,015 325 419 169 55 Occupational Medicine 2,626 1,864 1,571 1 292 529 41 83 109
Ophthalmology 18687 18,257 16,404 1,155 698 115 128 151 36 Oral & Maxillofacial Surgery 45 45 40 2 3 Orthopedic Surgery 21,824 21,359 17,216 3,094 1,049 114 134 76 141 Orthopedic Surgery of the Spine 518 511 466 23 22 4 1 2 Orthopedic Trauma 83 80 63 9 8 3 Osteopathic Manipulative Medicine 2 2 2
230
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
HOSPITAL BASED OTHER PROFESSIONAL ACTIVITY
SPECIALTY TOTAL TOTAL PATIENT
CARE
OFFICE BASED
RESID./ FELLOW
S
PHYS. STAFF ADMIN. MED.
TEACH. RESEARC
H OTHER
Other (ie, a specialty other than those appearing above) 4,933 3,176 1,682 1,172 322 707 132 762 156
Otolaryngology 9659 9473 7998 1043 432 67 81 26 12
Otology/Neurology 124 121 104 9 8 1 2 Pain Management 1,755 1,731 1,502 152 77 6 10 6 2 Pain Management (Physical Medicine & Rehabilitation) 17 17 17
Pain Medicine 192 186 174 12 1 3 1 1
Palliative medicine 86 57 42 15 14 4 3 8 Pediatric Emergency Medicine (Pediatrics) 548 516 234 192 90 8 17 6 1
Pediatrics/ Emergency Medicine 19 19 19 Pediatric Allergy 188 164 154 10 5 4 12 3
Pediatric Anesthesiology 373 366 245 102 19 2 5 Pediatric Cardiology 1842 1,701 1,269 238 194 25 31 78 7 Pediatric Cardiothoracic Surgery 37 35 24 11 1 1 Pediatric Critical Care Medicine 1,167 1,118 734 271 113 10 18 20 1 Pediatric Emergency Medicine (Emergency Medicine) 72 70 40 23 7 1 1
Pediatric Endocrinology 842 721 479 149 93 6 17 93 5 Pediatric Gastroenterology 595 561 366 142 53 8 8 15 3 Pediatric Hematology / Oncology 1,702 1449 973 283 193 27 26 193 7 Pediatric Infectious Disease 358 310 160 123 27 7 10 26 5 Pediatric Nephrology 507 425 287 85 53 13 25 41 3 Pediatric Ophthalmology 183 181 176 5 2 Pediatric Orthopedics 335 324 259 17 48 6 4 1
Pediatric Otolaryngology 134 131 104 16 11 3 Pediatric Pathology 114 104 72 19 13 2 2 2 4
231
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
HOSPITAL BASED OTHER PROFESSIONAL ACTIVITY
SPECIALTY TOTAL TOTAL PATIENT
CARE
OFFICE BASED
RESID./ FELLOW
S
PHYS. STAFF ADMIN. MED.
TEACH. RESEARC
H OTHER
Pediatric Psychiatry/Child Psychiatry 78 78 78 Pediatric Pulmonology 631 577 416 103 58 8 10 36 Pediatric Radiology 656 618 498 33 87 5 23 6 4 Pediatric Rehabilitation Medicine 3 2 1 1 1 Pediatric Rheumatology 120 97 57 32 8 1 4 16 2 Pediatric Surgery (Neurology) 32 31 25 6 1 Pediatric Surgery (Surgery) 796 743 608 52 83 10 25 16 2
Pediatric Urology 183 179 147 20 12 2 2 Pediatric/Physical Medicine & Rehabilitation 10 10 10
Pediatrics 56,945 54150 42,691 7298 4,161 1,019 835 718 223
Pediatrics/ Medical Genetics 7 7 7 Pediatrics/Dermatology 1 1 1 Pharmaceutical Medicine 66 6 6 8 1 37 14 Phlebology 37 37 36 1 Physical medicine & Rehabilitation 7,617 7,326 5,585 890 851 169 43 43 36 Plastic Surgery 6,577 6,466 5602 631 233 25 43 23 20 Plastic Surgery Within the Head & Neck 1 1 1 Proctology 1 1 1 Procedural Dermatology 21 21 21
Psychiatry 39,715 36,647 26,264 4,266 6,117 1,446 542 814 266 Psychiatry/Neurology 14 14 14 Psychoanalysis 531 513 505 8 6 5 5 2 Psychosomatic Medicine 9 9 8 1
232
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
HOSPITAL BASED OTHER PROFESSIONAL ACTIVITY
SPECIALTY TOTAL TOTAL PATIENT
CARE
OFFICE BASED
RESID./ FELLOW
S
PHYS. STAFF ADMIN. MED.
TEACH. RESEARC
H OTHER
Public Health and General Preventive Medicine 1,501 296 224 72 729 64 312 100
Pulmonary Critical Care Medicine 3,563 3,491 2372 964 155 7 17 45 3
Pulmonology 6,511 5,700 4,949 94 657 199 198 391 23 Radiation oncology 4,378 4,262 3,453 480 329 41 26 42 7 Radiological Physics 1 1 Radiology 4,932 4,530 3,878 2 650 79 126 74 123 Reproductive Endocrinology 628 565 504 61 14 22 25 2 Rheumatology 4,340 3,840 3,254 307 279 88 103 285 24 Selective Pathology 212 210 148 56 6 1 1 Sleep Medicine 132 116 99 3 14 6 2 7 1
Spinal Cord Injury Medicine 56 55 37 11 7 1 Sport Medicine (Orthopedic Surgery) 968 963 852 79 32 1 2 2 Sports Medicine (Emergency Medicine) 10 9 8 1 1 Sports Medicine (Family Practice) 393 390 320 54 16 1 2 Sports Medicine (Internal Medicine) 40 38 36 2 1 1 Sports Medicine (Pediatrics) 37 37 20 12 5 Sports Medicine (Physical Medicine & Rehabilitation) 12 12 10 2
Surgical Critical Care (Surgery) 532 517 375 95 46 3 5 6 1 Surgical Oncology 275 245 198 47 7 8 14 1 Thoracic Surgery 4,897 4,708 4,078 272 358 59 52 64 14 Transplant Surgery 124 111 92 19 3 4 4 2 Transplantation Medicine 1 1 1
Trauma Surgery 239 201 126 75 15 14 6 3 Undersea & Hyperbaric Medicine 53 44 30 14 6 1 2 Unspecified 6,311 6,045 4,294 1,212 539 64 35 112 55
233
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
HOSPITAL BASED OTHER PROFESSIONAL ACTIVITY
SPECIALTY TOTAL TOTAL PATIENT
CARE
OFFICE BASED
RESID./ FELLOW
S
PHYS. STAFF ADMIN. MED.
TEACH. RESEARC
H OTHER
Urgent Care Medicine 202 198 169 29 3 1 Urology 10,493 10,247 8,808 933 506 88 83 54 21 Vascular and interventional Radiology 1,445 1431 1,271 97 63 4 6 4 Vascular Medicine 21 20 19 1 1 Vascular Neurology 15 15 1 14 Vascular Surgery 2,494 2,388 2,039 164 185 39 39 21 7 Inactive 39,304
Not Classified 99,823 Address Unknown 488
Source: American Medical Association, 2007, Physician Characteristics and Distribution in the US, 2007 Edition
234
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table.No.4 Total Physicians by Specialty, Age & Gender
MALE PHYSICIANS BY AGE AND SELF-DESIGNATED SPECIALTY, 2005
FEMALE PHYSICIANS BY AGE AND SELF-DESIGNATED SPECIALTY, 2005 SPECIALTY
TOTAL UNDER 35 35-44 45-54 55-64 65 AND
OVER TOTAL UNDER 35 35-44 45-54 55-64 65 AND
OVER TOTAL PHYSICIANS 657,140 77,699 134,871 161,211 130,416 152,943 244,913 62,394 77,179 61,258 27,180 16,902
Aerospace Medicine 434 18 43 142 117 114 34 3 6 15 10
Allergy/ Immunology 3,031 175 454 887 925 590 1,081 172 329 332 191 57 Anesthesiology 31,492 3,608 8,694 10,926 5,590 2,674 9,002 1,522 2,766 2,807 1,357 550 Cardiovascular Disease 20,210 1,584 4,520 6,723 4,854 2,529 2,139 386 761 681 237 74 Child Psychiatry 3,952 223 921 1,143 1,006 659 3,282 340 1,080 1,064 540 258 Colon/ Rectal surgery 1,133 55 306 371 284 117 158 20 93 39 5 1 Dermatology 6,519 651 1,226 1,618 1,939 1,085 4,074 1,032 1,343 1,144 441 114 Diagnostic Radiology 18,858 3,015 4,650 5,664 4,121 1,408 5,373 1,188 1,835 1,627 626 97 Emergency Medicine 22,687 4,392 6,128 6,478 4,619 1,070 6,457 2,154 2,106 1,544 543 110
Family Medicine 54,307 6,337 13,816 18,175 10,992 4,987 27,394 7,301 10,267 7,235 2,095 496 Forensic Pathology 444 17 97 147 94 89 228 16 80 77 39 16 Gastroenterology 10,670 851 2,711 3,546 2,596 966 1,347 323 483 402 122 17 General Practice 8,950 38 222 1,376 2,648 4,666 2,099 19 123 577 795 585 General Preventive Medicine 1,392 104 415 429 258 186 819 113 287 297 76 46
General Surgery 32,387 5,871 7,187 7,438 6,817 5,074 5,470 2,249 1,736 1,081 323 81 Internal Medicine 105,987 17,627 25,793 30,375 21,386 10,806 48,015 13,606 16,338 12,520 4,454 1,097 Medical Genetics 259 26 59 73 62 39 239 30 68 80 47 14 Neurological surgery 5,111 714 1,300 1,307 1,007 783 329 89 116 99 20 5 Neurology 10,787 982 2,444 3,377 2,681 1,303 3,544 669 1,246 1,054 445 130 Nuclear Medicine 1,202 78 218 301 352 253 298 30 72 106 63 27 Obstetrics/ Gynecology 24,507 1,448 4,673 6,817 7,081 4,488 18,093 4,975 6,361 4,573 1,657 527
Occupational Medicine 2,110 7 120 722 674 587 516 4 80 262 117 53
235
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table.No.4 Total Physicians by Specialty, Age & Gender (Cont…)
SPECIALTY MALE PHYSICIANS BY AGE AND SELF-DESIGNATED SPECIALTY, 2005
FEMALE PHYSICIANS BY AGE AND SELF-DESIGNATED SPECIALTY, 2005
TOTAL UNDER 35 35-44 45-54 55-64 65 AND
OVER TOTAL UNDER 35 35-44 45-54 55-64 65 AND
OVER
Ophthalmology 15,498 1,311 3,358 4,322 3,965 2,542 3,372 699 1,191 1,007 363 112 Orthopedic Surgery 23,039 3,396 5,465 6,184 5,001 2,993 1,101 370 371 270 72 18 Otolaryngology 8,757 1,083 2,142 2,223 1,950 1,359 1,160 336 433 289 82 20 Pathology-Anatomic/ Clinical 12,795 946 2,433 3,528 3,112 2,776 6,544 991 1,823 2,052 1,147 531
Pediatric Cardiology 1,320 143 389 376 231 181 522 101 221 116 49 35 Pediatrics 33,875 5,191 7,963 9,132 7,447 4,142 38,413 10,927 12,593 9,092 4,409 1,392 Physical Medicine & Rehabilitation 5,047 674 1,671 1,548 756 398 2,638 448 936 712 377 165
Plastic Surgery 6,202 547 1,440 1,839 1,571 805 819 152 288 262 94 23 Psychiatry 27,663 1,951 4,330 6,959 7,475 6,948 13,935 2,242 3,367 4,352 2,651 1,323 Public Health & General Preventive Medicine
1,051 1 37 246 327 440 450 1 30 173 108 138
Pulmonology 8,574 852 2,259 2,743 2,063 657 1,500 278 666 402 115 39
Radiation Oncology 3,327 389 863 1,045 692 338 1,051 180 341 312 172 46 Radiology 7,473 380 1,914 1,416 1,740 2,023 1,340 82 436 390 304 128 Thoracic Surgery 4,722 151 1,056 1,453 1,176 886 175 18 72 63 20 2 Transplant Surgery 115 35 54 13 13 10 3 6 1 Urological Surgery 10,120 1,003 2,263 2,497 2,647 1,710 556 199 214 113 25 5 Vascular Medicine 16 4 2 7 3 5 3 2 Other Specialties 4,410 65 377 1,020 1,260 1,688 940 33 149 327 214 217 Unspecified 5,146 1,980 1,205 981 560 420 2,337 1,152 555 385 164 101
Inactive 87,383 27 687 2,662 6,942 77,065 12,440 25 630 1,880 2,030 7,875 Not Classified 23,836 9,784 8,983 2,942 1,290 837 15,468 7,919 5,279 1,457 556 257 Address Unknown 342 4 4 88 246 146 2 24 120
Source: American Medical Association, 2007, Physician Characteristics and Distribution in the US, 2007 Edition
236
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No 5. D.O.s by Specialty & Age
SPECIALTY TOTAL PHYSICIANS <35 35-44 45-54 55-64 >=65
TOTAL PHYSICIANS 57,449 12,468 16,226 15,061 7,211 6,483 Aerospace Medicine 94 4 5 35 32 18 Allergy/ Immunology 113 18 24 38 23 10 Anesthesiology 2,451 579 744 793 235 100 Cardiovascular Disease 669 74 217 255 107 16 Child Psychiatry 253 33 90 84 35 11 Colon/ Rectal surgery 18 3 3 4 4 4 Dermatology 403 63 122 132 62 24 Diagnostic Radiology 730 154 232 199 103 42 Emergency Medicine 3,251 550 1,072 1,115 452 62 Family Medicine 14,342 2,578 4,624 4,299 1792 1,049 Forensic Pathology 17 10 5 1 1 Gastroenterology 371 48 132 129 55 7 General Practice 3,319 11 329 1,224 993 762 General Preventive Medicine 223 19 61 86 39 18 General Surgery 1,096 266 380 256 106 88 Internal Medicine 6,576 1,844 2,220 1,701 611 200 Medical Genetics 6 3 2 1 Neurological surgery 70 7 26 23 10 4 Neurology 611 114 199 200 83 15 Nuclear Medicine 53 8 6 18 8 13 Obstetrics/ Gynecology 2,063 478 703 547 270 65 Occupational Medicine 229 23 126 61 19 Ophthalmology 385 33 126 127 71 28 Orthopedic Surgery 1,071 83 355 370 186 77 Otolaryngology 347 20 122 126 51 28 Pathology-Anatomic/ Clinical 433 108 89 115 85 36 Pediatric Cardiology 16 7 4 4 1 Pediatrics 2,522 1,016 787 447 213 59
237
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No 5. D.O.s by Specialty & Age (Cont…)
SPECIALTY TOTAL PHYSICIANS <35 35-44 45-54 55-64 >=65
Physical Medicine & Rehabilitation 1,009 299 343 262 68 37 Plastic Surgery 76 7 24 22 20 3 Psychiatry 1,425 296 313 460 240 116 Public Health & General Preventive Medicine 35 7 13 10 5 Pulmonology 379 58 114 138 65 4 Radiation Oncology 77 9 24 29 15 Radiology 398 24 103 84 108 79 Thoracic Surgery 66 2 16 26 18 4 Urological Surgery 181 13 43 74 38 13 Vascular Medicine 5 1 2 2 Other Specially 311 5 57 116 77 56 Unspecified 6,567 2,339 1,729 905 485 1,109 Inactive 2,748 1 86 307 317 2,037 Not Classified 2,440 1293 658 164 61 264
Source: American Medical Association, 2007, Physician Characteristics and Distribution in the US, 2007 Edition
238
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.6 Number of Osteopathic Physicians D.O.S CATEGORIES NUMBER
Number of living D.O.s 58,940 Number of active D.O.s under age 65 52,827 Number of D.O.s over age 65 6,113
Source: AOA (2007) Fact sheet 2006 [internet], AOA. Available from: <http://www.osteopathic.org/pdf/ost_factsheet.pdf> [Accessed September 2007] Table No.7 Active D.O.s by gender GENDER NUMBER PERCENTAGE
Total 52,827 100
Female 15,929 30.2
Male 36,898 69.8
Source: AOA (2007) Fact sheet 2006 [internet], AOA. Available from: <http://www.osteopathic.org/pdf/ost_factsheet.pdf> [Accessed September 2007] Table No.8 Active D.O.s by age category AGE CATEGORY (YEARS) NUMBER PERCENTAGE
Total 52,827 100
<35 13,230 25
35-44 16,911 32
45-54 15,142 28.7
55-64 7,117 13.5
Missing/ unknown 427 0.8
Source: AOA (2007) Fact sheet 2006 [internet], AOA. Available from: <http://www.osteopathic.org/pdf/ost_factsheet.pdf> [Accessed September 2007]
239
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.9 Active (in patient care) D.O.s by self-identified specialty category CATEGORY NUMBER PERCENTAGE
Total 52,827 100% Family medicine 18,234 35% Internal medicine 3,256 6% Pediatrics 1,660 3% OB/Gyn 1,544 3% OMT/OMM 459 1% Nonprimary care 14,115 27% Unknown 267 1% D.O.s assumed to be in postdoctoral training 13,292 25%
Source: AOA (2007) Fact sheet 2006 [internet], AOA. Available from: <http://www.osteopathic.org/pdf/ost_factsheet.pdf> [Accessed September 2007]
240
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.10 Physicians by Age & Location
STATE TOTAL PHYSICIANS <35 35-44 45-54 55-64 >= 65
TOTAL PHYSICIANS 902,053 140,093 212,050 222,469 157,596 169,845 Alabama 10,809 1,672 2,576 2,974 1,880 1,707 Alaska 1,643 143 460 463 350 227 Arizona 14,699 1,709 3,575 3,686 2,584 3,145 Arkansas 6,315 931 1,503 1,715 1,071 1,095 California 108,053 14,594 23,204 24,522 21,731 24,002 Colorado 13,816 1,762 3,512 3,520 2,528 2,494 Connecticut 14,234 2,224 3,230 3,616 2,429 2,735 Delaware 2,372 366 573 567 383 483 District Of Columbia 4,815 1,131 973 908 867 936 Florida 52,324 4,939 11,101 13,419 9,245 13,620 Georgia 22,222 3,212 5,813 6,002 3,636 3,559 Hawaii 4,528 547 1,013 1,183 881 904 Idaho 2,825 198 728 761 556 582 Illinois 38,513 7,883 8,941 8,852 6,596 6,241 Indians 14,977 2,172 3,706 4,122 2,537 2,440 Iowa 6,319 1,009 1,483 1,661 1,061 1,105 Kansas 6,978 1,005 1,642 1,743 1,230 1,358 Kentucky 10,646 1,628 2,704 2,770 1,841 1,703 Louisiana 12,650 2,236 2,975 3,041 2,212 2,186 Mains 4,095 374 889 1,130 798 904 Maryland 25,498 3,979 5,961 6,273 4,579 4,706 Massachusetts 31,908 6,293 7,964 7,325 5,115 5,211 Michigan 27,316 5,106 6,465 6,340 4,583 4,822 Minnesota 16,373 2,773 4,184 4,256 2,583 2,577 Mississippi 5,872 750 1,471 1,520 1,036 1,095 Missouri 15,322 2,957 3,709 3,788 2,468 2,400 Montana 2,496 109 540 732 545 570 Nebraska 4,727 834 1,180 1,215 733 765
241
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.10 Physicians by Age & Location (Cont…)
STATE TOTAL PHYSICIANS <35 35-44 45-54 55-64 >= 65
Nevada 5,196 519 1,457 1,270 874 1,076 New Hampshire 4,003 410 952 1,102 705 834 New Jersey 29,786 4,013 6,889 7,724 5,558 5,602 New Mexico 5,292 647 1,196 1,354 1,139 956 New York 82,301 15,818 18,117 18,788 13,686 15,892 North Carolina 24,698 4,055 6,437 6,515 3,705 3,986 North Dakota 1,712 188 435 463 339 287 Ohio 33,618 6,420 8,267 7,823 5,288 5,820 Oklahoma 6,950 933 1,501 1,804 1,329 1,383 Oregon 11,301 1,241 2,748 2,817 2,244 2,251 Pennsylvania 41,358 7,199 8,919 10,495 7,008 7,737 Rhoda Island 4,259 851 1,042 974 615 777 South Carolina 10,992 1,726 2,837 2,673 1,829 1,927 South Dakota 1,936 191 484 582 366 313 Tennessee 17,349 2,560 4,341 4,783 2,888 2,777 Texas 53,571 8,950 14,030 12,994 8,974 8,623 Utah 5,857 881 1,527 1,463 1,032 954 Vermont 2,624 368 574 687 470 525 Virginia 23,049 3,561 5,482 5,763 3,974 4,269 Washington 19,349 2,223 4,489 5,075 3,798 3,764 West Virginia 4,681 739 1,043 1,075 941 883 Wisconsin 15,855 2,222 4,157 4,316 2,508 2,652 Wyoming 1,113 71 261 307 230 244 Possessions 11,379 1,538 2,366 3,356 1,836 2,283 APO’s and FPO’s 991 229 422 158 90 92 Address Unknown 488 4 2 4 112 366 Source: American Medical Association, 2007, Physician Characteristics and Distribution in the US, 2007 Edition
242
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.11 Total Physicians by professional activity and Location
PATIENT CARE OTHER PROFESSIONAL ACTIVITY
HOSPITAL BASED STATE TOTAL TOTAL PATIENT
CARE
OFFICE BASED RESID/
FELLOWS PHYS. STAFF
ADMIN MED. TEACH. RESEARCH OTHERS
TOTAL PHYSICIANS 902,053 718,473 563,225 95,391 59,857 14,997 10,223 14,471 143,401
Alabama 10,809 9,020 7,305 1,134 581 135 91 136 1,427
Alaska 1,643 1,417 1,180 34 203 36 10 15 165
Arizona 14,699 11,385 9,546 962 877 249 160 138 2,767
Arkansas 6,315 5,247 4,259 636 352 60 91 49 868
California 108,053 84,424 70,352 8,368 5,704 1,810 1,035 1,837 18,947
Colorado 13,816 10,995 9,168 1,047 780 258 155 215 2,193
Connecticut 14,234 11,161 8,438 1,696 1,027 312 188 334 2,239
Delaware 2,372 1,891 1,516 203 172 43 20 27 391
District Of Columbia 4,815 3,629 2,246 858 525 196 111 152 727
Florida 52,324 39,848 33,841 2,786 3,221 724 456 406 10,890
Georgia 22,222 18,227 14,944 1,841 1,442 367 249 323 3,056
Hawaii 4,528 3,601 2,923 321 357 75 63 48 741
Idaho 2,825 2,321 2,087 68 166 35 17 8 444
Illinois 38,513 31,172 23,433 5,449 2,290 635 435 475 5,796
Indiana 14,977 12,450 10,238 1,263 949 205 150 180 1,992
Iowa 6,319 4,920 3,899 667 354 61 94 130 1,114
Kansas 6,978 5,591 4,488 664 439 90 94 56 1,147
Kentucky 10,646 8,833 7,268 1,017 548 136 119 80 1,478
Louisiana 12,650 10,509 8,266 1,554 689 142 193 107 1,699
Maine 4,095 3,214 2,656 211 347 92 52 29 708
Maryland 25,498 19,280 14,223 2,730 2,327 786 300 1,216 3,916
Massachusetts 31,908 24,567 17,482 4,631 2,454 599 315 1,188 5,239
Michigan 27,316 21,808 16,220 3,903 1,685 460 331 374 4,343
243
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.11 Total Physicians by professional activity and Location (Cont…)
PATIENT CARE OTHER PROFESSIONAL ACTIVITY
STATE TOTAL TOTAL PATIENT
CARE
OFFICE BASED HOSPITAL BASED ADMIN MED.
TEACH. RESEARCH OTHERS
Minnesota 16,373 13,177 10,392 1,967 818 243 177 287 2,489
Mississippi 5,872 4,815 3,866 460 489 73 52 32 900
Missouri 15,322 12,486 9,402 2,034 1,050 213 215 265 2,143
Montana 2,496 1,983 1,767 26 190 32 16 12 453
Nebraska 4,727 3,840 2,995 595 250 68 71 50 698
Nevada 5,196 4,241 3,732 202 307 68 30 19 838
New Hampshire 4,003 3,154 2,596 257 301 52 32 54 711
New Jersey 29,786 24,099 18,890 2,908 2,301 520 292 524 4,351
New Mexico 5,292 4,151 3,260 469 422 95 66 73 907
New York 82,301 65,260 44,688 13,319 7,253 1,574 1,026 1,591 12,850
North Carolina 24,698 19,785 15,779 2,511 1,495 380 305 447 3,781
North Dakota 1,712 1,422 1,162 113 147 27 20 5 238
Ohio 33,618 26,868 20,227 4,562 2,079 458 392 421 5,479
Oklahoma 6,950 5,590 4,521 650 419 102 96 44 1,118
Oregon 11,301 8,816 7,454 703 659 177 123 140 2,045
Pennsylvania 41,358 32,052 23,579 5,679 2,794 758 503 903 7,142
Rhode Island 4,259 3,444 2,477 623 344 77 46 64 628
South Carolina 10,992 9,074 7,266 1,053 755 140 158 85 1,535
South Dakota 1,936 1,597 1,329 95 173 24 15 6 294
Tennessee 17,349 14,367 11,716 1,767 884 247 200 224 2,311
Texas 53,571 44,311 35,515 5,874 2,922 734 704 621 7,201
Utah 5,857 4,722 3,810 615 297 99 60 103 873
Vermont 2,624 2,000 1,479 323 198 49 39 54 482
244
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006 Table No.11 Total Physicians by professional activity and Location (Cont…)
PATIENT CARE OTHER PROFESSIONAL ACTIVITY
STATE TOTAL TOTAL PATIENT
CARE
OFFICE BASED HOSPITAL BASED ADMIN MED.
TEACH. RESEARCH OTHERS
Virginia 23,049 18,503 14,374 2,347 1,782 408 248 250 3,640
Washington 19,349 15,016 12,477 1,324 1,215 349 198 401 3,385
West Virginia 4,681 3,793 2,861 549 383 62 76 33 717
Wisconsin 15,855 12,951 10,696 1,462 793 228 189 182 2,305
Wyoming 1,113 900 787 34 79 17 7 4 185
Possessions 11,379 9,672 7,700 806 1,166 184 133 47 1,343
APO’s end FPO’s 991 874 450 21 403 33 5 7 72
Address Unknown 488
Source: American Medical Association, 2007, Physician Characteristics and Distribution in the US, 2007 Edition