Transcript
Page 1: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK
Page 2: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 3: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

2

Should you have any questions or comments about this report then please feel free to

contact EphMRA as follows:

Bernadette Rogers

EphMRA General Secretary

[email protected]

www.ephmra.org

Feedback is always welcomed as we use this input to further improve other funded

projects.

Page 4: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 5: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

4

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

Page 6: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

5

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

Page 7: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

6

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

Page 8: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

7

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

Page 9: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

8

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

Page 10: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

9

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

Page 11: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

10

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

Page 12: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

11

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

Page 13: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

12

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.

Page 14: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

13

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.

Page 15: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

14

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

Page 16: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

15

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

Page 17: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

16

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

Page 18: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

17

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

Page 19: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

18

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

Page 20: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

19

USA

American Medical Association: Physician Statistics http://www.aoa-net.org/ American Osteopathic Association http://www.osteopathic.org/index.cfm?PageID=aoa_annualrprt

Page 21: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

20

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

Page 22: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

21

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

Page 23: Doctor Statistics - Canada, France, Germany, Italy, Japan, 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

Page 24: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

23

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.

Page 25: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

24

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.

Page 26: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

25

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.

Page 27: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

26

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.

Page 28: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

27

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.

Page 29: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

28

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.

Page 30: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

29

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.

Page 31: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

30

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.

Page 32: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

31

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.

Page 33: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

32

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

Page 34: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

33

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

Page 35: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 36: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 37: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

36

8. Canada

Page 38: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 39: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 40: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 41: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 42: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 43: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 44: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 45: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 46: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 47: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 48: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 49: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 50: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

49

ageing population, increasing health care expenditure, particularly for pharmaceuticals,

lengthy waiting times, and shortages of human resources, need to be addressed.

Page 51: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 52: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 53: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 54: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 55: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 56: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 57: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

56

9. France

Page 58: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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).

Page 59: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 60: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 61: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 62: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 63: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 64: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 65: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 66: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 67: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 68: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 69: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 70: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 71: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 72: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 73: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 74: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

73

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

Page 75: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

74

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]

Page 76: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

75

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

Page 77: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

76

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]

Page 78: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

77

10. GERMANY

Page 79: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 80: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 81: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

80

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

Page 82: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

81

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.

Page 83: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 84: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 85: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 86: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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,

Page 87: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 88: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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).

Page 89: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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).

Page 90: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 91: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 92: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 93: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 94: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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].

Page 95: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 96: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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].

Page 97: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 98: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

97

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].

Page 99: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

98

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

Page 100: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

99

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].

Page 101: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

100

11. Italy

Page 102: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

101

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

Page 103: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

102

(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

Page 104: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

103

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

Page 105: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

104

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.

Page 106: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

105

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

Page 107: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

106

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

Page 108: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

107

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.

Page 109: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

108

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

Page 110: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

109

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.

Page 111: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

110

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.

Page 112: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

111

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

Page 113: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

112

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].

Page 114: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

113

12. Japan

Page 115: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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).

Page 116: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

115

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

Page 117: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

116

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.

Page 118: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

117

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;

Page 119: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

118

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).

Page 120: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

119

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

Page 121: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

120

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

Page 122: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

121

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

Page 123: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

122

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.

Page 124: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

123

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.

Page 125: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 126: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 127: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 128: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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].

Page 129: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 130: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]..

Page 131: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

130

13. Spain

Page 132: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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).

Page 133: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

132

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

Page 134: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 135: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

134

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).

Page 136: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 137: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 138: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

137

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

Page 139: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 140: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 141: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

140

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).

Page 142: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 143: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 144: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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].

Page 145: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 146: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 147: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 148: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 149: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 150: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

149

14. UK

Page 151: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, 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

Page 152: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 153: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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).

Page 154: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 155: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 156: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 157: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 158: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 159: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 160: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 161: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

160

ENGLAND

Page 162: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 163: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 164: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 165: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 166: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 167: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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].

Page 168: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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 -

Page 169: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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 -

Page 170: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 171: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 172: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

171

NORTHERN IRELAND

Page 173: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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].

Page 174: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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].

Page 175: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 176: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 177: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

176

SCOTLAND

Page 178: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 179: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 180: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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].

Page 181: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 182: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 183: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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].

Page 184: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 185: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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 -

Page 186: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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 - - - - - -

Page 187: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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 -

Page 188: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 189: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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].

Page 190: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

189

WALES

Page 191: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 192: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 193: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 194: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 195: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 196: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

195

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]

Page 197: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 198: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 199: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 200: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

199

UK

(CONSOLIDATED DATA)

Page 201: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 202: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 203: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 204: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 205: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 206: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

205

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]

Page 207: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

206

15. USA

Page 208: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 209: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 210: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 211: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 212: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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;

Page 213: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 214: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 215: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 216: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 217: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 218: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 219: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 220: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

219

leading drugs, the strengthening of the Canadian versus the US dollar and restricted

availability of supplies were implicated in this slowdown.

Page 221: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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.

Page 222: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 223: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 224: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 225: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 226: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 227: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 228: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 229: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 230: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 231: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 232: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 233: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 234: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 235: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 236: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 237: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 238: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 239: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 240: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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]

Page 241: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 242: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 243: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 244: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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

Page 245: Doctor Statistics - Canada, France, Germany, Italy, Japan, Spain, UK

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