Fritz Beske Institut für Gesundheits-System-Forschung Kiel

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1 Fritz Beske Institut für Gesundheits-System-Forschung Kiel Gemeinnützige Stiftung STIFT UN G Kiel, On the situation of medical specialists and specialist health services in UEMS member states To assess the situation of specialist physicians working in UEMS member states available relevant data have been collated. The following tables give an overview of the total number of specialist physicians and in proportion to the population as well as an indication of accessibility to specialized medical services in selected countries. IGSF Weimarer Straße Kiel Tel. (04 31) Fax (04 31) info@igsf-stiftung.de

2 Situation of medical specialists in UEMS member states 2 Formatted: English (U.K.) Table 1 Absolute number of physicians in selected European countries Physicians Physicians full-time equivalent (FTE) Medical Surgical No of Physicians group of specialities Obstetric & gynaecological Paediatric General practitioners Austria n/a Belgium n/a Bulgaria n/a n/a n/a n/a n/a Cyprus n/a n/a Czech Republic Denmark Estonia Finland France n/a Germany Hungary Iceland Italy n/a n/a n/a n/a n/a Latvia n/a Lithuania Luxembourg n/a Malta n/a Netherlands n/a Norway

3 Situation of medical specialists in UEMS member states 3 Formatted: English (U.K.) Physicians Physicians full-time equivalent (FTE) Medical Surgical No of Physicians group of specialities Obstetric & gynaecological Paediatric General practitioners Poland n/a n/a Portugal n/a Romania n/a Slovakia Slovenia n/a Spain n/a Sweden n/a Switzerland n/a United Kingdom n/a n/a n/a n/a n/a , , , , , , n/a: figures not available Source: European health for all database (HFA-DB); WHO

4 Situation of medical specialists in UEMS member states 4 Formatted: English (U.K.) Table 1 presents the total number of physicians per country as well as the number of physicians for some specialist group. The specialities were grouped into three major categories because sub-specialities differ between countries and are therefore difficult to compare. The column full time equivalent sums up all physicians who work either full- or part-time as full time employed physicians. Comparisons between countries concerning specialist services are difficult because of differing health systems. One of the interesting features is that e.g. the number of specialist doctors in Germany is relatively higher than in France. Noteworthy is also that for the United Kingdom no figures on specialist groups are available. Table 2 Total number of physicians per population in selected European countries No of physicians Physicians full-time equivalent (FTE) per population Austria 365,8 n/a. Belgium 422,77 n/a Bulgaria 366,46 n/a Cyprus 252,94 n/a Czech Republic 356,45 335,55 Denmark 319,76 261,61 6 Estonia 328,53 313,65 Finland 328,66 284,95 France 337,85 n/a Germany 345,02 312,96 Hungary 303,58 319,12 Iceland 368,02 300,83 1 Italy 365,41 n/a Latvia 314,69 n/a Lithuania 398,05 503,14 Luxembourg 290,0 6 n/a Malta 384,79 n/a Netherlands 382,33 n/a Norway 374,09 347,91 Poland 203,18 n/a Portugal 242,56 6 n/a

5 Situation of medical specialists in UEMS member states 5 Formatted: English (U.K.) No of physicians Physicians full-time equivalent (FTE) per population Romania 192,06 n/a Slovakia 313, ,16 Slovenia 237,29 n/a Spain 368,61 n/a Sweden n/a Switzerland n/a United Kingdom 212,61 4 n/a , , , , , , n/a: figures not available Source: European health for all database (HFA-DB); WHO Table 2 shows the total number of physicians per population. As information from the same year was not available for all countries, the statistics had to include figures from a time frame ranging from 1997 to Belgium shows the highest total number of physicians per population which is double the figure of the United Kingdom, showing the difference between Bismarck and Beverage health care systems. Table 3 Number of specialist physicians per population in selected UEMS member countries Medical Physicians, group of specialities per population Surgical Obstetric & gynaecological Paediatric General practitioner Austria 104,6 56,94 18,18 13,22 150,80 Belgium 101,2 6 47,3 6 14, , ,3 6 Bulgaria n/a n/a n/a n/a 66,80 Cyprus 100,3 3 35, , ,3 3 n/a Czech Republic 132,08 58,78 23,19 32,60 70,50 Denmark 46,98 36,83 7,65 5,80 77,50 Estonia 124,22 47,49 20,24 17,90 63,50 Finland 92,55 35,83 11,92 10,50 95,90 France 82,3 33,59 8,27 11,00 165,10 Germany 139,97 56,02 18,48 12,90 99,10 Hungary 138,79 31,53 12,16 26,00 65,10 Iceland 116,32 58,49 12,16 17,70 77,93 5

6 Situation of medical specialists in UEMS member states 6 Formatted: English (U.K.) Medical Physicians, group of specialities per population Surgical Obstetric & gynaecological Paediatric General practitioner Italy n/a n/a n/a n/a 91,60 Latvia 92,05 44,36 20,50 13,60 56,10 Lithuania 137,36 54,71 23,57 37,40 76,60 Luxembourg 107, , , ,0 6 92,5 6 Malta 26, ,44 7,13 11,10 82,6 2 Netherlands 40, ,43 6 5,51 6 7, ,00 Norway 189,5 21,71 10,88 12,90 75,30 Poland 166,36 16,86 13,36 16,30 n/a Portugal 113, , , ,9 6 56,1 6 Romania 46,9 19,08 9,31 10,00 68,70 Slovakia 151, , , ,9 5 43,3 6 Slovenia 68,86 31,07 11,90 18,60 48,80 Spain 48,03 43,82 9,69 7,80 73,80 Sweden 80,37 41, ,17 14,20 60,40 Switzerland 137,49 54,73 15,70 16,20 52,40 United Kingdom n/a n/a n/a n/a n/a , , , , , , n/a: figures not available Source: European health for all database (HFA-DB); WHO Table 3 offers an interesting overview on the varying distribution of medical specialists per population in different countries. It is noteworthy that e. g. in Norway more than double as many specialist physicians/population are working than in Sweden, whereas the ratio of surgical specialities is the inverse in the two countries. Significant differences in the distribution of specialities exist also e. g. between France and Germany, where the latter has a significant higher ratio among physicians, surgeons and gynaecologists, whereas France has almost 70 percent more general practitioners per population than Germany.

7 Situation of medical specialists in UEMS member states 7 Formatted: English (U.K.) Table 4 countries Percentage of physicians working in hospitals in selected European % of physicians working in hospitals Austria 65,2 Belgium 38,8 4 Bulgaria 43,6 Cyprus n/a Czech Republic 25,7 Denmark 74,5 Estonia 51,9 Finland 50,1 France 29,8 Germany 46,9 Hungary 38,4 Iceland 63,0 5 Italy 62,0 Latvia 43,0 3 Lithuania 43,5 Luxembourg n/a Malta 30,1 2 Netherlands n/a Norway 60,0 Poland n/a Portugal 73,8 7 Romania 53,3 Slovakia 52,0 7 Slovenia 57,9 Spain 45,1 Sweden 71,1 1 Switzerland 46,0 United Kingdom 67, , , , , , , , n/a: figures not available Table 4 shows remarkable differences between selected European countries in the proportion of physicians working in hospitals. General practitioners work traditionally

8 Situation of medical specialists in UEMS member states 8 Formatted: English (U.K.) in private practice. As expected a relatively high proportion of physicians 60 percent and more, are employed in hospitals in countries with a state health system, e.g. United Kingdom, Norway or Denmark, but also in Austria, with a well developed private specialist sector, the majority of physicians are employed in hospitals. Table 5 Patient s access to medical specialist treatment in the European Union Austria Belgium Bulgaria Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Iceland Patient s access to medical specialist treatment In general referral required by the general practitioner. Free choice for patients and free access to doctors. Upon general practitioner referral. Only through referral by general practitioner. Patients are given direct access which is not restricted by a gate-keeping system. Group 1: The general practitioner refers each particular case to the specialist. Group 2: Free access to specialist without general practitioner referral. Access to specialists by referral of the patient's general practitioner. Access to psychiatrist, gynaecologist, dermatovenereologist, oculist, traumatologist or surgeon in case of emergency surgery is possible without a referral from the general practitioner. For specialised medical care in public sector a referral from a doctor in either the public or private sector needed. No referral needed to a specialist working in private sector. General scheme for employees (Régime général d'assurance maladie des travailleurs salariés, RGAMTS): Through referral by the general practitioner. Otherwise, the patient's copayment is higher. Free access to certain specialities or in case of urgency or of displacement. Free choice among contracted specialists. The insured are allowed to visit the specialists in the regional institution of the social insurance institute by appointment according to a waiting list. In urgent cases patients also have direct access to a private specialist. Upon referral by general practitioner except in cases of emergency and for specified treatments that are specifically exempt from the referral requirement such as dermatology, gynaecology, laryngology, ambulatory surgery and accident/emergency surgery, ophthalmology, oncology, urology, psychiatry. However the referral is addressed to the type of speciality and to a service provider who is geographically obliged to the maintenance of the care, the patient can enjoy the free choice of specialist. Maintenance of the care can only be refused if it would endanger the care of those patients who are living in that geographical area which the specialist is bound to. Direct access.

9 Situation of medical specialists in UEMS member states 9 Formatted: English (U.K.) Patient s access to medical specialist treatment Italy Latvia Lithuania Only through referral by general practitioner and only specialists at the local Health Centres (Unità Sanitarie Locali, USL) are covered for. Referral from general practitioner required except dentists for children, oncologist, gynaecologist, psychiatrist, TB specialist, endocrinologist, dermatologist, narcologist and in case of emergencies. Only through referral by general practitioner exept for visit to dermatovenerologist. Luxembourg No restriction for seeing a specialist. Malta Only through referral by general practitioner. Netherlands Only through referral by general practitioner. Poland Portugal Romania Slovenia Slovakia Spain Sweden United Kingdom Source: MISSOC 2008 Free choice of and direct access to certain specialists e.g. gynaecologists, dermatologists, psychiatrists and oncologists working in contracted health centres. In other cases upon referral from the general practitioner. Free choice of general practitioner/specialist working either in health centres or under agreement. Free choice of the specialist if the patient is referred by general practitioner. No referral needed in cases of: medical emergency family planning alternative medicine. Referral by a general practitioner. Patients visit specialists on the basis of a referral from their general practitioner. Referral via general practitioner. Direct access is possible, but referral via the general practitioner is preferred. Referral by a general practitioner. There is no direct access to specialists. Table 5 is fairly self explanatory and highlights the difference between countries with state health systems such as the United Kingdom and the Netherlands and countries with private medical care systems. In general, access to medical specialists in anglosaxon countries and in some countries of the former Eastern European health systems is only possible through referral from general practitioners, who function as gate keepers.

10 Situation of medical specialists in UEMS member states 10 Formatted: English (U.K.) Table 6 Waiting time for treatment Familiy doctor same day access Indicator Waiting time for treatment Direct access to specialist Major nonacute operations < 90 days Cancer therapy < 21 days MRI scan < 7 days Austria Belgium Bulgaria Cyprus Czech Republic Denmark Estonia Finland France Germany Hungary Iceland n/a n/a n/a n/a n/a Italy Latvia Lithuania Luxembourg Malta Netherlands Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden Switzerland United Kingdom = good, + = intermediary, - = poor, n/a: figures not available Source: Euro-health Consumer Report 2008, modified table

11 Situation of medical specialists in UEMS member states 11 Formatted: English (U.K.) Table 6 is extracted and modified from the Euro-health Consumer Report 2008, published by the Health Consumer Powerhouse, a Swedish think tank on health policies, that has published The Empowerment of the European Patient 2009 options and implications. This report reviews certain aspects of health care systems in the European countries. One of the indicators presented in this study shows the waiting time for treatment for specific urgent and non-urgent services, representing critical bottlenecks in health service delivery. It is evident that direct access to specialist services is established in countries with a well developed private health care sector such as Austria, Germany and France. On the other hand, state health systems such as the anglo-saxon countries and countries of the former Eastern Block do not/or only to a very limited extent offer direct access to specialist services. In Detail Table 6 shows the waiting time for family doctors with same day access, direct access to specialist, major non-acute operations under 90 days, cancer therapy under 21 days and MRI scan under 7 days. Family doctor same day access. There is good access in Austria, Belgium, Bulgaria, Czech Republik, Denmark, Germany, Luxembourg, Malta, Romania and Slovakia. In these countries patients can visit their family doctor without any waiting time. Intermediary waiting time is found in Cyprus, Estonia, France, Hungary, Italy, Lithuania, Netherlands, Norway, Poland, Spain, Switzerland and the United Kingdom. In Finland, Latvia, Portugal, Slovenia and Sweden same day access to family doctor is poor, which means there are waiting times for access to general practitioners in 19 percent of the selected countries. Direct access to specialist. Direct access to specialists is reported from Austria, Belgium, Cyprus, Czech Republic, Germany, Luxembourg and Switzerland. In France, Hungary, Italy, Lithuania, Poland and Romania waiting time for access ist intermediary. No direct access to specialists have patients in Bulgaria, Denmark, Estonia, Finland, Latvia, Malta, Netherlands, Norway, Portugal, Slovakia, Slovenia, Spain, Sweden and the United Kingdom. In these countries, direct access is reported as poor, meaning that in 52 percent of selected countries patients have no direct access zu specialists.

12 Situation of medical specialists in UEMS member states 12 Formatted: English (U.K.) Major non-acute operations < 90 days. Belgium, Estonia, France, Germany, Luxembourg and Switzerland have a good health care system with reference to waiting times under 90 days for major non-acute operations.. Intermediary waiting time is reported from Austria, Bulgaria, Czech Republic, Denmark, Estonia, France, Hungary, Italy, Lithuania, Netherlands, Norway, Romania and Slovenia. In 37 percent of selected countries, waiting time for major non-acute operations is poor i.e. long. These countries include Cyprus, Finland, Latvia, Malta, Poland, Portugal, Slovakia, Spain, Sweden and the United Kingdom. Cancer therapy < 21 days. In Belgium, Estonia, France, Germany, Hungary, Luxembourg, Netherlands, Slovakia and Switzerland, waiting time for cancer therapy is under 21 days, this is a good result. Intermediary is waiting time for cancer therapy in Austria, Bulgaria, Cyprus, Czech Republic, Denmark, Finland, Italy, Lithuania, Malta, Norway, Poland, Portugal, Romania, Spain, Sweden and the United Kingdom. 7 percent of selected countries have higher waiting times for cancer therapy there is a poor result for this indicator in Latvia and Slovenia. MRI scan < 7 days. A good result with reference to the indicator waiting time for MRI scan under 7 days have the following countries: Austria, Estonia, Hungary, Romania and Switzerland. Intermediary waiting times have Bulgaria, Germany, Luxembourg, Netherlands and Slovakia. Waiting times over 7 days are normally found in Belgium, Cyprus, Czech Republik, Denmark, Finland, France, Italy, Latvia, Lithuania, Malta, Norway, Poland, Portugal, Slovenia, Spain, Sweden and the United Kingdom, i.e. in 63 percent of selected countries.