Marco Teórico
2.3.3 LA GLOBALIZACION EN LAS NUEVAS TECNOLOGÍAS
9.37 Our economic analysis of competition in the medical practitioners’ profession set out below entails an empirical examination of a range issues in relation to market size, structure and the patterns of demand for medical services. Our analysis draws from a number of information sources, as follows:
- Data obtained from the Medical Council, Comhairle na
nOspidéal, the Irish Hospital Consultants Association, the Irish Medical Organisation, and the Irish College of General
Practitioners;
- New information obtained from the Indecon Survey of Medical Practitioners (of which there were 473 responses); - New information obtained from the Indecon Survey of Health
Insurance Companies; and,
- New information obtained by the Indecon Survey of the Public (sample size of 1,008 adults aged 15+).
Section 9 Competition and the Medical Practitioners’ Profession in Ireland
Number and Growth in Medical Practitioners
9.38 A useful indicator of the size of the market for supply of medical services, and one that can be straightforwardly measured, is the population and recent growth in the number of medical practitioners. In this section we look at a number of indicators of the supply of medical practitioners based on data sourced from the Medical Council, the Indecon Survey of Medical Practitioners and the Irish College of General Practitioners.
9.39 In Table 9.4 below we present details from the General Register of Medical Practitioners, which is maintained by the Medical Council. A key regulatory requirement for medical professionals in Ireland is that one must be registered on the General Register to practise as a registered medical practitioner.
Table 9.4: General Register of Medical Practitioners - Number of Fully and Temporary Registered Doctors - 1991-2002
Year Fully % change Temp Total* % change
1991 9,329 - 818 10,147 - 1992 9,375 0.5 880 10,255 1.1 1993 9,642 2.8 854 10,496 2.4 1994 9,824 1.9 818 10,642 1.4 1995 10,452 6.4 898 11,350 6.7 1996 10,580 1.2 849 11,429 0.7 1997 10,807 2.1 1,037 11,844 3.6 1998 11,240 4.0 1,294 12,534 5.8 1999 11,600 3.2 1,311 12,911 3.0 2000 11,907 2.6 1,065 12,972 0.5 2001 13,004 9.2 1,271 14,275 10.0 2002 13,761 5.8 1,273 15,034 5.3 % average annual change 1991-1996 2.5 0.7 2.4 1997-2002 5.0 4.2 4.9
* Excludes Interns, of which there are typically 400-450 registered each year. Source: The Medical Council.
Indecon- London Economics
Section 9 Competition and the Medical Practitioners’ Profession in Ireland
9.40 According to the figures, there were 15,034 persons on the General Register of Medical Practitioners as at September 2002, of which 13,671 were fully registered and 1,273 were temporarily registered (i.e. those who may apply for registration and are awaiting full registration). It is also instructive to note the recent growth in the numbers on the Register, which has fluctuated significantly on a year- to-year basis since the early 1990s. However, it is noticeable that the average annual rate of increase in the numbers of doctors on the Register has increased from 2.5% per annum between 1991-1996 to 5% per annum between 1997 and 2002 in respect of fully registered doctors. The total number of doctors on the Register (i.e. including those temporarily registered) has increased on average by 4.9% per annum since 1997, compared with an average annual increase of 2.4% between 1991 and 1996.
9.41 To place these figures in context, the population of Ireland increased by 11% between 1991 and 2002, compared with an increase of 47.5% in the total number of fully registered medical practitioners over this period. However, the demand for medical services is also likely to be influenced by the overall level of income and wealth of the population and it is notable in this regard that the numbers in the profession have grown less rapidly than the Irish economy, which expanded at an average annual rate in real terms of 6.95% between 1992 and 2001.4
9.42 A comparison of the number of inhabitants per doctor/physician across 14 European countries in 2000 is presented in Table 9.5. It is notable that Ireland ranks 13th out of 14 European countries in relation to the number of inhabitants per doctor, which stood at 425 in 2000.
Section 9 Competition and the Medical Practitioners’ Profession in Ireland
Table 9.5: Comparison of Number of Inhabitants per Doctor/Physician – 2000
Country No. of Inhabitants per
Doctor/Physician Italy 173 Austria 178 Greece 221 Spain 223 Norway 252 Belgium 259 Germany 267 France 280 Sweden 311 Portugal 316 Finland 320 Denmark 341 Ireland 425 United Kingdom 508
Source: IMD, World Competitiveness Yearbook, 2002
9.43 Another perspective on the General Register of Medical Practitioners can be obtained by considering the annual number of new registrants. In Table 9.6 below we describe the annual number of new registrants according to those that are fully registered and temporarily registered, over the period 1995-2002. The Medical Council figures indicate that the annual number of new full registrants has increased continuously from 609 in 1995 to 966 in 2002. The number of temporarily registered doctors has fluctuated considerably and this has partly reflected the impact of the Council’s Temporary Registration Assessment Scheme (TRAS). The purpose of the TRAS is to offer postgraduate training opportunities in Ireland to doctors who have qualified in medical schools outside the EU. Temporary registration can be a route to full registration, and is available for a total of up to seven years.
Indecon- London Economics
Section 9 Competition and the Medical Practitioners’ Profession in Ireland
Table 9.6: General Register of Medical Practitioners - Breakdown of Annual New Registrants - 1995-2002
Year Full-time Temp*
1995 609 323 1996 626 457 1997 686 609 1998 687 97** 1999 718 44** 2000 758 155 2001 960 410 2002 966 455
*All new registrants for temporary registration would have qualified outside the EU.
**In December 1997 the Medical Council introduced the TRAS (Temporary Registration Assessment Scheme). As a result, the number of doctors granted initial temporary registration fell dramatically. Doctors have now become used to the TRAS and the figures have stabilised.
Source: The Medical Council.
9.44 The Medical Council has, since 1 January 1997, also maintained a Register of Medical Specialists, for doctors who have completed specialist training in a speciality recognised by the Council. It is useful to examine the numbers on this Register, shown in Table 9.7 below. The Register of Medical Specialists has grown steadily since its inception in 1997 and there are currently 1,697 specialists on the Register. It should be noted that practitioners registered on the Register of Medical Specialists must also have their names entered in the General Register of Medical Practitioners.
Table 9.7: General Register of Medical Practitioners - Number of Doctors on Register of Medical Specialists - 1997-2002
Year Register of Medical Specialists % change
1997 352 1998 539 53.1 1999 730 35.4 2000 965 32.2 2001 1,493 54.7 2002 1,697 13.7
Section 9 Competition and the Medical Practitioners’ Profession in Ireland
9.45 The General Register of Medical Practitioners indicates those individuals entitled to practise medicine as registered practitioners in Ireland. However, for a variety of reasons, including those doctors registered in Ireland but living abroad, education, ill-health, retirements, etc, the practice status of individuals is likely to differ from the total number on the Register. In Table 9.8 the estimated number of doctors practising in Ireland by area of practice is indicated based on estimates supplied by the Medical Council and data from Comhairle na nOspidéal. Overall, it is estimated that there are close to 9,000 doctors practising in Ireland, of which 2,691 or 30.1% are General Practitioners, 2,067 (23.1%) are consultants, and 3,542 (39.6%) are Non-Consultant Hospital Doctors (NCHDs), while the remainder (652 or 7.3%) are doctors employed mainly in public health medicine, academic posts and the defence forces.
Table 9.8: Estimated No. of Doctors Practising in Ireland by Practice Status
Practitioners by Area Estimated No. %
General Practitioners 2,691 30.1
Consultants1 2,067 23.1
Non-Consultant Hospital Doctors2 3,542 39.6
Other3 652 7.3
Estimated total practitioners 8,952 100
Source: The Medical Council, Survey of Registered Medical Practitioners, 2001. Extrapolated totals based on survey response of 3,169 doctors working in Ireland.
1 Includes 1,632 permanent public consultant posts, 262 non-permanent posts, and an estimated 173
specialists in private practice – Comhairle na nOispideal, Consultant Staffing, January 2002.
2 Includes temporarily registered doctors and interns.
3 Includes doctors in public health medicine, academic posts and the defence forces.
9.46 In Table 9.9 we indicate the number of public sector permanent medical consultant posts over the period 1990-2002, based on figures provided by Comhairle na nOspidéal. As of January 2002, there were 1,632 public consultant posts in Ireland. This compared with 1,440 posts in 2000, 1,216 posts in 1995 and 1,122 posts in 1990. The annual net increase in the number of public consultant posts has risen noticeably since the late-1990s, and in 2001 an additional 120 permanent posts were created.
Indecon- London Economics
Section 9 Competition and the Medical Practitioners’ Profession in Ireland
Table 9.9: Number of Public Sector Permanent Consultant Posts - 1990-2002 Year Consultant Posts Total Permanent Net Annual Increase Population per Consultant
1991 1,139 17 3,095 1992 1,158 19 - 1993 1,170 12 - 1994 1,186 16 - 1995 1,216 30 - 1996 1,270 54 2,855 1997 1,292 22 2,833 1998 1,327 35 2,792 1999 1,388 61 2,698 2000 1,440 52 2,630 2001 1,560 120 2,461 2002 1,632 72 2,388
Source: Comhairle na nOspidéal, Consultant Staffing, January 2002 and Indecon calculations.
9.47 One indicator of the supply of the number of medical consultants is the ratio of the total population to the number of consultant posts. According to our calculations, there were 2,855 persons per public consultant in 1996 and this ratio has been falling on an annual basis since 1996, to a level of 2,388 persons per public consultant in 2002. 9.48 In addition to public consultants, as stated earlier there are also
consultants working exclusively within a private capacity. While accurate figures are not available on the number of private consultants, Comhairle na nOspidéal has estimated that in 2001 there were 173 doctors engaged as specialists in private practice in private hospitals or clinics who are not employed as consultants or NCHDs in public hospitals. The majority of these consultants operate in the Eastern Regional Health Authority area. However, it should be noted that around 600 consultants employed in public hospitals hold Category 2 contracts and are therefore entitled to also work in a private capacity. In addition, the figure quoted above does not include consultants who have retired from public work and who continue to work in private hospitals.
Section 9 Competition and the Medical Practitioners’ Profession in Ireland
Changes in Fee Income of Medical Practitioners
9.49 Another important aspect of the market for the provision of medical services in Ireland concerns the growth in fee income generated by medical practitioners. In the Indecon Survey of Medical Practitioners, we asked GPs to state the approximate average annual change in total fee income generated by their practice over the three-year period 1999-2001. The survey findings are shown in Table 9.10.
9.50 According to the survey findings, the vast majority (97.5%) of GP practices responding to our survey indicated an increase in their fee income on an average annual basis over the period 1999-2001. It is also notable that of those stating an increase in fee income, the largest proportion of GPs surveyed (46.4%) indicated that their fee income increased by between 10 and 24% on an average annual basis over the period 1999-2001, while 27.9% stated that fee income rose by 5-9% on average. A total of 11.5% of GPs responding to our survey indicated that their fee income increased on average by up to 4% over this period. By contrast, only 2.5% of GPs responding to our survey saw a decrease in their fee income on an average annual basis over the last three years. Of those practices that experienced a fall in fee income, 45.5% stated that their income fell by up to 4%, while 27.3% stated that their fee income decreased by between 5-9%, and a further 27.3% noting that their income fell by between 10-24%.
Table 9.10: Indecon Survey of Medical Practitioners - Approximate Average Annual Change in Total Fee Income of GP Practices - 1999-
2001
Extent of change in fees % reporting Increase % reporting Decrease GP practices stating increase/decrease in fee
income 97.5 2.5 Of which: Over 200% 0.2 0 150-199% 0.7 0 100-149% 1.2 0 50-99% 3.9 0 25-49% 8.1 0 10-24% 46.4 27.3 5-9% 27.9 27.3 0-4% 11.5 45.5
Source: Indecon Survey of Medical Practitioners.
Indecon- London Economics
Section 9 Competition and the Medical Practitioners’ Profession in Ireland
Practice Status of Members of the Medical Profession
9.51 Another feature of the profession which has implications for the nature of supply of medical services, concerns the practice status of members of the medical profession, including the structure of GP practices and the extent to which doctors work full-time and part-time or on a permanent or temporary basis. In Table 9.11 and Table 9.12 below we present some evidence concerning the practice status of medical professionals based on a survey carried out by the Irish College of General Practitioners (ICGPs).
9.52 An indication of the typical structure of GPs practices can be seen from the ICGP survey findings in Table 9.11. According to the figures, the majority (51%) of GPs responding to the survey stated that they operated within a sole practitioner capacity, while 35% stated that they worked as a partner within a practice. It was also stated that GPs worked as assistants (7%), sessional GPs (4%), trainees (1%) or locums (2%).
Table 9.11: Irish College of General Practitioners - Survey Data on Position of GPs within Practice
Position % Single GP 51 Partner 35 Assistant 7 Sessional 4 Trainee 1 Locum 2 Total 100
Source: Irish College of General Practitioners, National Survey of General Practice, Final Report – 2000, based on data collected in September 1996.
9.53 The vast majority of GPs (87%) operate on a full-time basis, with only 13% working on a part-time basis, according to the ICGP survey findings (see Table 9.12). In addition, 89% of those responding to the survey worked on a permanent basis.
Section 9 Competition and the Medical Practitioners’ Profession in Ireland
Table 9.12: Irish College of General Practitioners - Survey Data on Tenure of GPs in Practice Tenure % Full-time 87 Part-time 13 Permanent 89 Temporary 11
Source: Irish College of General Practitioners, National Survey of General Practice, Final Report - 2000, based on data collected in September 1996.
Size Distribution of GP Practices
9.54 An indication of the current size distribution of GP practices can be seen from the findings from our Survey of Doctors, shown in Table 9.13 below. According to the figures, the average number of doctors per GP practice in Ireland has remained constant over the last three years, while the median indicates that GPs tend largely to be sole practitioners. However, it is noteworthy that there is a large standard deviation around the average of 1.7 doctors per practice, indicating variation in the size of GP practices.
Table 9.13: Indecon Survey of Doctors - Statistics on Practice Size Number of doctors per practice
Statistics 1999 2000 2001
Average number of doctors per practice 1.7 1.7 1.7
Median number of doctors per practice 1.0 1.0 1.0
Standard deviation 1.1 1.1 1.2
Standard deviation - % of mean 66.3 67.6 70.4
Source: Indecon Survey of Doctors.
Indecon- London Economics
Section 9 Competition and the Medical Practitioners’ Profession in Ireland
9.55 Further evidence concerning the typical size of GP practices can be seen by examining the findings of the Irish College of General Practitioners survey of general practice. While the survey is based on 1996 figures, it is notable that 42% of operations were single GP practices, while 28% of practices were comprised of 2 GPs. A further 15% of GPs stated that they worked within a practice of three GPs, while 14% worked within practices of 4 or more practitioners (see Table 9.14). The predominance of single-doctor or small practices may have implications for the scale and variety of services that can be provided to patients and may also limit the ability of smaller practices to compete and invest in equipment and facilities.
Table 9.14: Irish College of General Practitioners - Survey Data on Practice Size
Practice size - No. of GPs %
1 42 2 28 3 15 4+ 14
Source: Irish College of General Practitioners, National Survey of General Practice, Final Report - 2000, based on data collected in September 1996.
Section 9 Competition and the Medical Practitioners’ Profession in Ireland